Adjusting general damages values using equalization values

ABSTRACT

A selection is made from a defined list of one or more equalization criteria. Based on the selected equalization criteria, equalization values are derived from a set of closed claim data. During processing of open claims, bodily injury data for the open claims are entered into the system. For one or more of the open claims, precedent claims that match the open claim are identified based on characteristics of the open claim. A value for one or more of the matching precedent claims is adjusted using the previously determined equalization values. An amount for use in settling the open claim is determined based on the adjusted value.

PRIORITY CLAIM

This application claims priority to U.S. Provisional Patent ApplicationSer. No. 61/022,140 filed on Jan. 18, 2008 entitled: “SYSTEM AND METHODFOR EVALUATING EFFECTIVENESS OF INSURANCE CLAIMS ASSESSMENT ANDNEGOTIATION” and U.S. Provisional Patent Application Ser. No. 61/053,556filed on May 15, 2008, entitled “SYSTEM AND METHOD FOR DETERMININGAMOUNTS FOR SETTLING INSURANCE CLAIMS”, the disclosures of which ishereby incorporated by reference as if fully set forth herein.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention generally relates to methods of assessment andnegotiation of insurance claims. Certain embodiments relate to systemsand methods of evaluating the effectiveness and consistency of computerprocesses and systems used in insurance assessment and negotiation.

2. Description of the Related Art

Insurance companies have been processing and settling claims associatedwith bodily injury for a long time. The task of evaluating, analyzing orestimating the amount of damage associated with one or more types ofbodily injuries, especially trauma-induced bodily injuries, can be verycomplex. Complexity in the evaluation process often arises out of thefact that concurrent expertise in legal, medical and insurance fields isoften required to arrive at a particular decision involving a bodilyinjury claim.

Several factors can affect the estimated amount of the claim associatedwith a bodily injury. Every accident is different and every injury isunique. Arriving at a customized evaluation of a bodily injury claim,which is unique for a specific accident, injury, etc. is desirable.Applying across-the-board standards may tend to result in an inequitablesolution for one or more parties involved. External environmentalfactors, such as the experience level of a claims adjuster, record ofaccomplishment of the legal professionals, post-injury quality of lifefor the injured party, etc., all may affect the valuation of a claim.

Many insurance companies have been using computer-based andknowledge-based claim-processing systems to process, evaluate, analyzeand estimate thousands or even millions of claims in what is intended tobe a fair and consistent manner. A knowledge-based claim-processingsystem may include an expert system which utilizes and builds aknowledge base to assist the user in decision making. Such a system mayallow the insurance companies to define new business rules and/or usepreviously defined rules, in real-time. The business rules are generallywritten by industry experts to evaluate legal, medical, insuranceconditions before arriving at a valuation of a claim.

The use of assessment tools can improve the fairness and equity in claimadjusting, especially the equity between claimants with similar claims.However, there is often significant variation in the values of similarclaims. In many instances, these variations may be warranted by theindividual nuances of a particular claim. However, there are also anumber of claims with widely disparate values that likely have no realmaterial differences to warrant these disparate values. For any giveninsurer, there may be a number of precedent claims in the insurer'sclosed claim database that embody the best practices for a particularcandidate claim; however, finding and presenting these claims to theinsurer's claim team as a basis for closing the candidate claim may notbe possible due to the sheer size of the database and the difficulty inmatching the essential features of a claim with the available tools ormethods.

Even where assessment tools for claims adjustment and negotiation arebeing used (or considered for use) by an organization, it may bedifficult to assess how useful or consistent the values (e.g., dollaramounts) being generated using the system are.

SUMMARY

Various embodiments of determining and displaying amounts for use insettling insurance claims are disclosed. In an embodiment, closed claimsthat match an open claim are identified based on one or morecharacteristics of the open claim. A likelihood value associated with atleast one of the matching closed claims is determined. An amount for useby an adjuster in settling the open claim (e.g., a general damagesamount or a recommended payout amount) is determined based on thelikelihood value for at least one of the matching claims. A most likelyamount and most likely range associated with the open claim may bedetermined based on the likelihood values. In certain embodiments,likelihood values are determined using kernel density estimation.

In an embodiment, likelihood values are determined for one or moreclosed claims that match an open claim. A graph is displayed of thelikelihood values as a function of an amount (e.g., general damagesamount). The graph may be an x-y graph in which the x-axis is amount andthe y-axis is likelihood value. The graph may include a likelihoodcurve. In certain embodiments, a band to corresponding a most likelyrange of amounts is shown on the graph. The band may include, forexample, all the claims within a specified percentage of a most likelyvalue for an open claim. The band may provide a visual aid to anadjuster in choosing an amount for settling the open claim.

In an embodiment, a selection is made from a defined list of one or moreequalization criteria. Based on the selected equalization criteria,equalization values are derived from a set of closed claim data. Theselection of the equalization criteria and the derivation ofequalization values may be accomplished during installation of aclaims-matching program onto a computer system. During use of theclaims-matching program to process open claims, bodily injury data forthe open claims are entered into the system. For one or more of the openclaims, precedent claims that match the open claim are identified basedon characteristics of the open claim. A value for one or more of thematching precedent claims (e.g., a general damages value) is adjustedusing the previously determined equalization values. An amount for usein settling the open claim (e.g., a recommended settlement amount) isdetermined based on the adjusted value.

In an embodiment, precedent claims that match a pending claim areidentified. A general damages amount is determined based on thelikelihood value for at least one of the matching precedent claims. Ageneral damages amount is derived from the likelihood value for at leastone of the matching precedent claims. Pending claim adjustments arecalculated based on amounts associated with the pending claim. Pendingclaim adjustments are applied to (e.g., added to or subtracted from) thegeneral damages amount to determine a recommended settlement amount. Incertain embodiments, pending claim adjustments are applied to anadjusted general damages range derived from the precedent claims todetermine a recommended settlement range.

Various embodiments of evaluating processes for insurance claimestimation and settlement are disclosed. In an embodiment, data isprovided for closed claims that have been previously settled using anestimation and settlement process. Each closed claim in the data istreated as a candidate claim. For each candidate closed claim, a set ofclosed claims similar to the candidate closed claim is identified basedon characteristics of the candidate closed claim. For each set ofsimilar claims so identified, a representative value for the set ofsimilar claims, such as an arithmetic mean, is determined. Thesettlement values for the candidate closed claims are compared to therepresentative values for the sets of similar closed claims. Theconsistency of the claims estimation and settlement process is evaluatedbased on the comparison. In certain embodiments, a potential benefit ofchanging or improving the estimation and settlement process is projectedbased on the comparison. The projection may be used in benefit studies,quality assessments, or the like.

In an embodiment, a method of evaluating an insurance claim estimationand settlement process includes providing candidate claims, each havingan associated general damages value. For each candidate claim, a set ofclaims that are similar to a candidate claim is identified based oncharacteristics of the candidate claim and the similar claims. Arepresentative general damages value for the set of similar claims isdetermined. A total general damages value is calculated for all thecandidate claims. A total representative general damages value isdetermined for the sets of similar claims associated with the candidateclaims. A difference between the total general damages value for thecandidate claims and total representative general damages value for thesets of similar claims is calculated.

In some embodiments, claims in a set of similar claims are grouped intotwo or more zones based on the values of the claims. A representativevalue for the set of similar claims may be based on values determinedfor claims in one or more of the zones, (such as an average value forthe claims in a mid-zone). The representative value for the set ofsimilar claims may be compared to the value for a candidate claim.

BRIEF DESCRIPTION OF THE DRAWINGS

A better understanding of the present invention may be obtained when thefollowing detailed description of preferred embodiments is considered inconjunction with the following drawings, in which:

FIG. 1 illustrates a computer system suitable for implementing variousembodiments.

FIG. 2 illustrates matching of candidate claims to precedent claimsaccording to one embodiment.

FIG. 3 illustrates a summary report for a set of precedent claims for asoft tissue injury according to one embodiment.

FIG. 4 illustrates a summary report for a set of precedent claims for afracture injury according to one embodiment.

FIG. 5 illustrates grouping of a claim set into zones according to oneembodiment.

FIG. 6 illustrates determining an amount for use in settling an openclaim using likelihood estimation according to one embodiment.

FIG. 7 illustrates determining amounts for settling open claims using alikelihood function according to one embodiment.

FIG. 8 shows a set of matches for an open claim.

FIG. 9 is a graph of likelihood values for a data set for an open claim.

FIG. 10 illustrates displaying likelihood values for a set of precedentclaims matching an open claim according to one embodiment.

FIG. 11 illustrates a display of likelihood values for a set of claimsmatching an open claim according to one embodiment.

FIG. 12 illustrates displaying summary amounts to a user based on adisplay mode selected by the user.

FIG. 13 illustrates determining equalization values based on definedequalization criteria for a system and processing open claims using thedetermined equalization values.

FIG. 14 illustrates determining recommended settlement amounts andranges with adjustments to adjusted general damages values for matchingprecedent claims.

FIG. 15 illustrates determining an effectiveness of a process using aclosed claim-to-closed claim comparison according to one embodiment.

FIG. 16 illustrates evaluation of a claim estimation and settlementprocess in which evaluation includes determining differences betweenvalues for candidate closed claims and representative values for similarclosed claims, according to one embodiment.

FIG. 17 illustrates an example of results from a closed claimmathematical analysis.

FIG. 18 illustrates a column chart reporting the matching frequency fora claim set according to one embodiment.

While the invention is susceptible to various modifications andalternative forms, specific embodiments thereof are shown by way ofexample in the drawings and will herein be described in detail. Itshould be understood, however, that the drawings and detaileddescription thereto are not intended to limit the invention to theparticular form disclosed, but on the contrary, the intention is tocover all modifications, equivalents and alternatives falling within thespirit and scope of the present invention as defined by the appendedrequests. Note, the headings are for organizational purposes only andare not meant to be used to limit or interpret the description orclaims. Furthermore, note that the word “may” is used throughout thisapplication in a permissive sense (i.e., having the potential to, beingable to), not a mandatory sense (i.e., must). The term “include”, andderivations thereof, mean “including, but not limited to”. The term“coupled” means “directly or indirectly connected”.

DETAILED DESCRIPTION OF ILLUSTRATIVE EMBODIMENTS

FIG. 1 illustrates an embodiment of computer system 250 that may besuitable for implementing various embodiments of a system and method forprocessing claims. Each computer system 250 typically includescomponents such as CPU 252 with an associated memory medium such asdisks 260. The memory medium may store program instructions for computerprograms. The program instructions may be executable by CPU 252.Computer system 250 may further include a display device such as monitor254, an alphanumeric input device such as keyboard 256, and adirectional input device such as mouse 258. Computer system 250 may beoperable to execute the computer programs to implementcomputer-implemented systems and methods for processing claims.

Computer system 250 may include a memory medium on which computerprograms according to various embodiments may be stored. The term“memory medium” is intended to include an installation medium, e.g., aCD-ROM, a computer system memory such as DRAM, SRAM, EDO RAM, RambusRAM, etc., or a non-volatile memory such as a magnetic media, e.g., ahard drive or optical storage. The memory medium may also include othertypes of memory or combinations thereof. In addition, the memory mediummay be located in a first computer, which executes the programs or maybe located in a second different computer, which connects to the firstcomputer over a network. In the latter instance, the second computer mayprovide the program instructions to the first computer for execution.Computer system 250 may take various forms such as a personal computersystem, mainframe computer system, workstation, network appliance,Internet appliance, personal digital assistant (“PDA”), televisionsystem or other device. In general, the term “computer system” may referto any device having a processor that executes instructions from amemory medium.

The memory medium may store a software program or programs operable toimplement a method for processing insurance claims. The softwareprogram(s) may be implemented in various ways, including, but notlimited to, procedure-based techniques, component-based techniques,and/or object-oriented techniques, among others. For example, thesoftware programs may be implemented using C#, ASP.NET, HTML,JavaScript, Java, ActiveX controls, C++ objects, JavaBeans, MicrosoftFoundation Classes (“MFC”), browser-based applications (e.g., Javaapplets), traditional programs, or other technologies or methodologies,as desired. A CPU such as host CPU 252 executing code and data from thememory medium may include a means for creating and executing thesoftware program or programs according to the embodiments describedherein.

Various embodiments may use a service-oriented architecture. In a systemusing service-oriented architecture, functions may be defined using adescription language. Interfaces may be invoked to perform businessprocesses. The interfaces may be independent of the platform on whichthe systems operate. Therefore, the services may be used regardless ofthe device, operating system, or communication protocol.

In some embodiments, a system includes a rule and calculation engine.The rule and calculation engine may also allow a user to configure thesystem to meet particular business needs.

In some embodiments, a system includes a thin-client common front end.The common front end may provide a single claims view for all types ofclaims. Views can be tailored to specific types of users, such as callcenter representatives, who handle notification and status calls, andback-office claims processors and adjudicators.

In some embodiments, a back office system may be provided. Back officeusers may handle more complex business processes and processes thatremain active over a longer period of time. The back office may includeaccess to management reports. Through the back office, managers may haveaccess to all functions within their business unit in order to provideadvice and to handle issues. In one embodiment, the back office may beprovided as a thin client.

As used herein, “FSO” means financial services organization. An FSO maybe an organization such as an insurance carrier or a bank. FSO alsoincludes any company, organization, or other entity that covers risk andassesses claims, including entities that self-insure.

As used herein, “general damages” generally refers to general damagesrelating to an injury or accident. General damages may include damagesrelating to pain and suffering, permanent impairment, disability, lossof enjoyment of life, and disfigurement.

As used herein, a “closed” claim means a claim that has been settled.

As used herein, an “open” means to a claim that has yet to be settled.

As used herein, “precedents” generally refer to acts or instances thatmay be used as an example in dealing with subsequent similar instances.Applying this interpretation to bodily injury claims, precedent findingincludes the act of comparing the facts of a bodily injury claim tobodily injury claims that have occurred previously, to find similarclaims and to compare the “outcome” of these claims with each other. Forthis purpose, the “outcome” of a bodily injury claim can be the monetarysettlement, or award in respect of general damages assessed or awardedfor injuries suffered.

As used herein, a “candidate claim” includes a claim that beingconsidered for adjustment, evaluation, estimation, assessment, orcomparison. The candidate claim may be, for example, an open claim forwhich a process of estimation, negotiation, and settlement needs to becarried out by an insurer.

As used herein, a “match” includes a claim that is identified for acandidate claim based on one or more similarities to the candidateclaim. For example, a closed claim relating to a broken radius bone maybe found to match a candidate claim relating to a broken ulna bone. Amatch need not require that the characteristics of a claim be identicalto the candidate claim. The degree of similarity that a system uses toproduce a match may be controlled to produce a set of matching claimsthat are relevant to a claims negotiation process.

As used herein, “monetary amount” means an amount of money. A monetaryamount may be expressed in any terms that indicate or correspond tofinancial value. In some embodiments, a monetary amount may be expressedin the form of a currency, such as dollars, euros, or yen.

As used herein, “likelihood value” generally refers to a valuecorresponding to or representing the likelihood of a condition or event.For example, a likelihood value may provide a measure of the likelihoodthat the monetary value associated with a particular closed claimmatching an open claim represents an appropriate value for use insettling the open claim.

As used herein, “most likely value” generally refers to a value derivedfrom a set of two or more values that, based on an established set ofcriteria, is most likely to represent a good value for settlement of aclaim. A “most likely range” generally refers to a range of valuesderived from a set of two or more values that, based on an establishedset of criteria, is most likely to represent a good range for settlementof a claim.

As used herein, an “adjusted value” generally refers to a value that isadjusted (increased or decreased) from an original value based on one ormore criteria. In some embodiments, an adjustment may be made for one ormore differences between a candidate claim and a matching claim.

As used herein, “equalization” generally refers to a process of findingand/or accounting for relativities between settlement general damagesamounts with different characteristics (e.g., for differentjurisdictions or for different litigation types). For example, when asystem is installed, a set of equalization values (e.g., coefficientvalues) may be derived from a set of closed claims data and stored in adatabase. During use of the system to process open claims, theequalization values may be retrieved from the database and used toadjust the values of matching precedent claims to account fordifferences between the characteristics of the open claim and thecharacteristics of the matching precedent claims. As used herein,equalization does not require that the value of any one claim be madeequal to that of any other claim.

Claims Matching and Analysis

In an embodiment, a system allows an adjuster to compare each open andits relevant factors to other similar closed claims to determine commonattributes so that the adjuster can better assess the value of eachclaim. The value of a claim may be, for example, a general damages valuefor a bodily injury claim. The system may include a database that coversall the closed claims data of a particular FSO. Details of such claimsmay be accessed by the adjuster to assist the adjuster in assessingvalues for new claims with the same or similar factors. Similar claimsthat significantly vary in value can be reviewed by the adjuster tounderstand what unique factors may have been present in the prior claimto determine whether that prior claim may have relevance to the currentclaim.

FIG. 2 illustrates matching of candidate claims to precedent claimsaccording to one embodiment. At 300, one or more claims are identifiedthat are similar to a candidate claim based on one or morecharacteristics of the candidate claim. The identification of similarclaims may be carried out automatically using a computer system. In oneembodiment, a claims matching process may be performed using PRECEDENTID™, available from Computer Sciences Corporation (CSC).

At 302, information concerning the matching claims may be presented toan adjuster. The information may include information on individualclaims, as well as information concerning the set of claims as a whole.For example, statistical information concerning the matching claims maybe presented to the adjuster.

At 304, a value for the candidate claim is estimated. The value may bebased on the value of one or more of the matching claims. In someembodiments, the estimated value for the candidate claim may be the sameas a particular matching claim. In other embodiments, the estimatedvalue may be based on statistical information (e.g., an average) for oneor more of the matching claims.

At 306, the value of the candidate claim may be used in a process forsettling the claim. In some cases, the negotiation process for aparticular open claim may include more than one matching procedure. Forexample, an initial offer may be made to a claimant based on onematching procedure. After a counter-offer is received, a second matchingprocess may be carried out to support an analysis of whether to acceptthe counter-offer or to formulate a response to the counter-offer.

FIG. 3 illustrates an example summary for a set of precedent claims fora soft tissue injury according to one embodiment. FIG. 4 illustrates anexample summary for a set of precedent claims for fracture injuryaccording to one embodiment.

Various characteristics of a candidate claim and/or precedent claims maybe used in determining a matching set of claims. For a bodily injuryclaim, examples of characteristics that may be considered include thenature of any injuries, the treatment modalities, the injurystabilization period, the nature of any complications, the medicaloutcome and prognoses, and the degree of any residual permanentimpairment. In certain embodiments, additional data including mitigatingfactors, attorney name, vehicle impact, and/or driving while under theinfluence, may be considered.

In some embodiments, a system or program for automatically identifyingsimilar cases may be used in combination with a general assessment tool.In one embodiment, an adjuster may use COLOSSUS®, available fromComputer Sciences Corporation, as a general assessment tool. Thus, anadjuster may have a general assessment program and a catalog ofprecedent cases to assist the adjuster in determining an appropriatevalue for the claim and to aid in the negotiation process.

If one looks for a precedent for a claim with a broken leg then onemight look at claims that involved a fractured femur, patella, tibia orfibula. These however are not similar injuries. The femur and tibia arethe two major weight bearing bones of the lower extremity and areconsidered much more serious injuries than fractures of the fibula andpatella, and this would be reflected in the settlement or verdictamount. Furthermore, even if the broken leg were in fact a fracturedfemur, not all previous cases of fractured femur would necessarily besimilar cases. In assessing General Damages for an injury, the natureand type of injury is not assessed in isolation. One also has to assesspain and suffering for the trauma of the treatment and its duration, andthe complications that may arise from the injury and also theoutcome—whether the injury heals or results in residual dysfunction andimpairment, and the degree of such.

In some embodiments, the system collates and presents the outcome ofclosely similar finalized claims. An insurer's collection of finalizedclaims includes claims settled by negotiation, those determined byarbitration or mediation and those determined through the court process(verdicts). Finalized cases reflect the opinions and evaluations ofadjusters and their peers, attorneys, injured parties, arbitrators andjuries, and therefore collectively may be a fair and true reflection ofthe potential value of a given claim.

While many people would agree that a fracture will be worth more than acontusion, the actual monetary damages assessed for a given injury underparticular circumstances can be subject to some disagreement. There canalso be disagreement over the order of many injuries in regard to theirrelative value to each other. These disagreements may be resolved byconsidering the claims that have already been finalized throughsettlement, arbitration or verdict.

In an embodiment, relative values or severities of injuries andassessment behavior may be learned from a database of finalized claims.The relative difference between the contusion and fracture are exhibitedin the finalized claims already present. The system may use data miningtechnologies to learn the relative values of such injuries and manyothers, from the tangle of injuries present in the finalized claims.This technology is also used to determine the impact that varioustreatments and complications have on the value of claims, as well asother medical and non-medical attributes. These include such things asthe jurisdiction, i.e., how damages for particular injuries vary fromstate to state and county to county, and litigation stage, i.e., whetherthe claim was settled with or without attorney representation andwhether a suit was filed.

Once the relative values of jurisdictions, injuries, treatments andother claim attributes have been learned then finding precedent claimscan be constrained by these as well as other factors. For instance,attempting to locate an existing case matching exactly the attributes ofa new fractured femur claim would probably prove fruitless. Imagine thevery specific medical and non-medical features of a real fractured femurclaim: the actual medical treatment, the specific period under care, theprognostic expectation, the impact on lifestyle to this individual, toname only some. It is doubtful whether another claim would exist in anyinsurer's database which matched exactly these features. Thus theprocess of locating precedent claims may include consideration of whatthe key features of this claim are and finding other claims which sharethese key features—a close match rather than an exact match. The systemmay determine for example that if there was both a contusion and afracture in a claim that the contusion was not a key feature of theclaim. The knowledge gained from data mining the finalized claims mayform the basis of determining what is important and what is not inclaims, and how this varies from claim to claim.

Matching may include input of precise and comprehensive injury and claimdata to successfully search for similar claims, including the nature ofinjuries, the treatment modalities, injury stabilization period, natureof any complication, the medical outcome and prognoses, and the degreeof any residual permanent impairment or disability.

Apart from claim data, other important information to be stored in thefinalized claims database includes the financial outcome of each claim.The General Damages component for all settlements, arbitration awardsand verdicts may be stored for each claim along with all the othercomponents of the settlement.

As discussed above, mathematical models may be applied to theinformation relating to matched claims. Statistical measures such asmean or median for the claim set may be determined and presented to theuser.

In some embodiments, claims with similar adjusted general damagesamounts are grouped into zones. In determining the zones, typicallythree are produced, but there may be fewer depending on how many claimsare found as matches. The objective in determining zones can beexpressed as determining where to place the dividing lines between thevalues in order to make three good clusters. Good clusters may becharacterized by the ‘closeness’ of the values to each other in acluster.

FIG. 5 illustrates grouping of a claim set into zones according to oneembodiment. At 340, claims are identified that are similar to acandidate claim. At 342, an initial grouping of the claims is made. At344, the sum of the squared errors is calculated by taking the mean ofthe values in a cluster, finding the difference between each value andthe mean, squaring the difference, and computing the sum for all of theclaims. At 346, the dividing line is iteratively moved between values todetermine the group of values with the lowest sum of squared errors.

In an embodiment, the precedent claims are divided in three groups—High,Medium and Low. For each of the groups the system calculates theminimum, maximum and weighted average value (e.g., general damagesvalue) and the number of claims. The system also needs to derive thevalues which separate the groups.

Typically, three bands may be calculated. However, there may be fewerbands. In this case the high band is discarded first, then the middleband.

Values may be derived to separate the groups, or bands, in order toplace the claims into these bands. In this case of three bands, the taskis to find the two values that represent the dividing lines between thelow and medium bands, and the dividing line between the medium and highbands. These two values may be found by regression (a stepwise processof refinement of the solution). The regression process starts bydividing the claims into three groups in increasing order of value. Thevalue may be, for example, a General Damages amount or medicals amount,depending on which are being derived at the time. Claims are initiallyallocated with equal numbers in each group (as far as equal numbers canbe achieved, the total number may not be exactly divisible by 3, e.g. 10claims). The values which separate the groups are then calculated as themid-points of the claims on either side. In other words, the separatorvalue between the low and medium groups is calculated as half waybetween the highest claims in the low group and the lowest claim in themedium group.

The next task is to see if the separator values can be changed in someway in order to derive more compact groups of values, or a tighterconfiguration of claims in the groups. To measure compactness, ortightness of values, we use the sum of the squared errors—in this casethe squared errors between each claim in a group and the average valuefor that group. If the sum of the squared errors decreases then theclaims values in a group will form a tighter cluster. An iterative taskis performed, which moves the separator values in the direction of thedecreasing total squared error, for all the three groups combined. Inother words, it modifies the separator values until it has the tightestfit for the three bands.

To illustrate a sum of the squared errors calculation in a simpleexample, a set of 100 values are to fit into 2 clusters. Cluster A andcluster B may be divided into zones using the following approach:

-   -   1. Sort the values into ascending sequence,    -   2. Initially set the dividing line such that it splits the        values equally, 50 values on each side of the line—therefore 50        values for cluster A and 50 for B.    -   3. Calculate the sum squared error for cluster A by finding the        mean of the 50 values in A and then taking the square of the        difference between the mean and each value in A, and summing        them, and then do the same for B. The total squared error is the        sum of the squared errors for A and B.    -   4. Move the dividing line up and down in single value        increments, and redistribute the values accordingly between A        and B, then recalculate the total error. Continue until the        total error cannot be reduced any more. In mathematical terms,        the foregoing description is a regression to find the best split        by descending the squared error surface.

Table 1 is an example of a set of similar claims for which can begrouped into zones according to one embodiment. Table 2 is an example ofa sequence of iterations used to group the claims in Table 1. Tosimplify the illustration, only two zones (Group A and Group B) aredetermined in the example.

TABLE 1 Claim ID Value ($) M 4,000.00 N 4,200.00 O 5,000.00 P 5,100.00 Q5,200.00 R 5,300.00

TABLE 2 Squared Group Mean ($) Error Iteration 1 Group A M, N, O4,400.00 560,000.00 Group B P, Q, R 5,200.00 20,000.00 Sum Squared580,000.00 Error Iteration 2 Group A M, N, O, P 4,575.00 652,400.00Group B Q, R 5,250.00 5,000.00 Sum Squared 657,400.00 Error Iteration 3Group A M, N 4,100.00 20,000.00 Group B O, P, Q, R 5,150.00 50,000.00Sum Squared 70,000.00 Error Iteration 4 Group A M 4,000.00 0.00 Group BN, O, P, Q, R 4,960.00 772,000.00 Sum Squared 772,000.00 ErrorReferring to Table 2, a first iteration is performed with the claimsevenly divided—claims M, N, and O in Group A, and claims P, Q, and R inGroup B. The sum squared error is calculated for Iteration 1. Subsequentiterations may be carried out until the grouping with the lowest sumsquared error is found. In this case, Iteration 3, in which Group Aincludes claims M ($4,000) and N ($4,200) and Group B includes claims O($5,000), P ($5,100), Q ($5,200), and R ($5,300), is associated with thelowest sum squared error (70,000) of all the iterations. This groupingmay be used in mathematical models support claim assessment, processevaluation, or other purposes.

In some embodiments, once the zones for a set of claims are established,an average for each zone is calculated using a weighted averagecalculation that considers the similarity (i.e., more similarattributes) of the precedent claims to the candidate claim.

In order to derive a weighted average, a weight is calculated for eachclaim, based on its similarity to the candidate claim, For example, anage of the claimant and the impairment as attributes to measure forclaim similarity. For whiplash claims, duration of treatment, generalpractitioner visits, specialist visits, physical therapy, andchiropractic visits as attributes may be used to measure for claimsimilarity,

A ratio is first developed which is calculated as the absolutedifference between the candidate claim's attribute value and theprecedent claim's attribute value, divided by the size of the zone usedin the search for this attribute. For instance, if the candidate claimhad a claimant age of 40 and the search used an age range of 30-50 (thisrange is purely hypothetical and will be influenced by search filtersand algorithms) then the age band is 20. If the precedent claim had aclaimant age of 45 then the age attribute ratio would be (45-40)/20 or0.25. Ratios are calculated for all the relevant claim attributes. Thenan average ratio is derived from all the relevant attribute ratios thathave been calculated. The weight is then 1 minus the average ratio, allsquared. Therefore, if the claim is very similar to the candidate claimthen the weight will be close to 1, while if it has significantdissimilarities then the weight can be close to zero (e.g., 0.0025).

The weighted average is then calculated by multiplying each precedentclaim's value (e.g., adjusted General Damages) by its weight, giving itsweighted value. The weighted values for all the claims in a cluster aresummed and then divided by the sum of the weights for all precedentmatches to the candidate claim. The result is the weighted average.

Determining Amounts for Claims Settlement Using Likelihood Values

FIG. 6 illustrates determining an amount for use in settling an openclaim using likelihood estimation according to one embodiment. At 400,an automated system may be used to identify one or more closed claimsthat match an open claim. Each of the closed claims may be associatedwith a corresponding monetary amount. In one embodiment, the monetaryamounts are general damages. At 402, a likelihood value is determinedwith respect to each of the closed claims.

At 404, one or more amounts are determined for the open claim based onthe likelihood values for the matching closed claims. The amounts may bemonetary amounts. An adjuster may use the monetary amounts in settlingthe open claim. For example, the monetary amount may be used as aproposed payout amount for the open claim.

Monetary amounts may be representative of a value for any of variousaspects of the claim. For example, a monetary amount may represent ageneral damages value, a medicals value, a settled value, or a payoutvalue. In some embodiments, monetary amounts may be presented to anadjuster as a Most Likely Amount or Most Likely Range.

At 406, one or more of the amounts are displayed. In some embodiments,likelihood values for the matching claims are displayed as a function ofamount (e.g., in an x-y graph). At 408, likelihood values associatedwith the matching claims are graphically displayed. The amounts andlikelihood values may be displayed simultaneously or on separatescreens.

In some embodiments, likelihood values are determined using kerneldensity estimation. Kernel density estimations methods suitable forembodiments described herein may be found in “Very fast optimalbandwidth selection for univariate kernel density estimation” by VikasChandrakant Raykar and Ramani Duraiswami (Dec. 20, 2005,CS-TR-4774/UMIACS-TR-2005-73), which is incorporated herein by referenceas if fully set forth herein. In certain embodiments, likelihood valuesfor matching claims are determined using maximum likelihood estimation.

FIG. 7 illustrates determining amounts for settling open claims using alikelihood function according to one embodiment. At 420, a set of claims(e.g., closed claims) that match an open claim is determined. At 422, afunction is determined with respect to each of the matching claims inthe set. In one embodiment, a Gaussian function is derived for eachclaim in the set of claims. In one embodiment, a Gaussian curve has amean of 0 and a variance of 1. A suitable bandwidth is determined forthe function. One method for determining bandwidth may be that given inthe Raykar paper.

At 424, a likelihood function is derived for the entire set of matchingclaims from the functions for the individual claims. In someembodiments, the likelihood function is the sum of the functions for theindividual claims.

In some embodiments, kernel density estimation is accomplished using afast density derivative estimation. In other embodiments, kernel densityestimation is accomplished using a solve-the-equation plug-in method. Inone embodiment, a fast density derivative method is used for relativelylarge sets (e.g., 20 or more points), and a solve-the-equation plug-inmethod is used for smaller sets.

At 426, likelihood values are determined with respect to each matchingclaim in the set. At 428, amounts for settling the open claim aredetermined based on the likelihood values of the matching claims. Insome embodiments, an amount for settling is the amount associated withthe closed claim with the highest likelihood value. In certainembodiments, a rank or rating may be assigned to each of the matchingclaims based on the likelihood value. One or more ranges may bedetermined. Each range may include all claims falling within a specifiedportion of the likelihood curve. In one embodiment, a range is definedto include all the claims having values within about the top quartile ofthe likelihood curve. In another embodiment, a range is defined toinclude all claims within a specified percentage of a most likely value.In one embodiment, a range is defined to include all claims within about10% of a most likely value.

At 430, amounts for use in settling the open claim are displayed. Theamounts may include specific values and/or ranges of values. At 432,likelihood values associated with the matching claims are displayed as afunction of amount.

FIG. 8 illustrates an example of a data set for an open claim. FIG. 9 isa graph of likelihood values for the data set shown in FIG. 8. Table 440includes data for a set of claims that match a candidate claim. Column442 indicates the candidate claim for which the matching claims arefound. In this case, the candidate claim is identified as claim numberCWW110001001. Column 444 indicates closed claims that were found tomatch claim CWW110001001. A unique claim number identifies each of thematching claims. Column 446 indicates a rating for each closed claim.Column 448 indicates an adjusted dollar value for each of the closedclaims. Column 450 indicates a general damages value before adjustment.

Column 452 indicates a likelihood value associated with each claim. Thelikelihood value may be based on a likelihood function determined asdescribed above with respect to FIG. 7. In the data set shown in FIG. 8,the following is used for the kernel density estimate:

${\hat{p}(x)} = {\frac{1}{N\sqrt{2\pi \; h^{2}}}{\sum\limits_{i = 1}^{N}^{{{- {({x - x_{i}})}^{2}}/2}h^{2}}}}$

where N is the number of points, x_(i) is the value of a point, and h isa bandwidth. Bandwidth may be selected by estimating an asymptotic meanintegrated squared error (AMISE)-optimal bandwidth. In one embodiment,the values for both matching claims that were paid at the policy limitand matching claims that were not paid at the policy limit are combinedinto a single list. Likelihood values may be calculated for all of thevalues on the combined list.

The rating shown in column 446 may provide an indicator of how usefulthe value for a claim might be in settling the open claim. The ratingmay reflect how close a match the candidate claim is to the matchedclaim in regards to data on the claim. In this example, claim number0000017267001 has a rating of 1. Point 462 shown in FIG. 9, which isassociated with claim number 0000017267001, is near the middle of theupper range of the likelihood curve. As another example, claim number0000004399001 has a rating of 4. Point 464 shown in FIG. 9, which isassociated with claim number 0000004399001, is on the lower fringe ofthe likelihood curve.

In some embodiments, a rating associated with a claim value may be basedon the claim's position within a cluster of points. For example, points463, 464, and 465 may be considered to form a cluster. The claimassociated with point 465 may be given a relatively high rating becausepoint 465 is in the middle of the cluster. In some embodiments, a value(e.g., dollar amount) associated with the highest rated point in acluster may be used as a representative value. For example, $3,123.46,which is the amount associated with point 465, may be used as arepresentative value.

Displaying Likelihood Values for Use in Settlement

FIG. 10 illustrates displaying likelihood values for a set of precedentclaims matching an open claim according to one embodiment. At 470,precedent claims that match an open claim are identified. At 472, alikelihood value is determined with respect to each of the matchingprecedent claims. At 474, a graph of likelihood values associated withthe matching precedent claims as a function of amount is displayed. At476, one or more ranges of amounts are indicated on the graph.

FIG. 11 illustrates a display of likelihood values for a set of claimsmatching an open claim according to one embodiment. Display 480 includesgraph portion 482 and summary portion 484.

Graph portion 482 of display 480 includes general damages graph 486.General damages graph 486 includes a curve showing likelihood values asa function of general damages. In the embodiment illustrated in FIG. 11,the curves are represented by specific discrete points (X's). The curvesmay, however, be represented by a continuous curve or any other discreteor continuous symbology. General damages graph 486 and medicals graph488 may provide a user with a visual representation of values for thematching claims. General damages graph 482 may allow an adjuster toidentify a cluster of a values and select a value from the cluster,rather than for example, just picking a value from a textual list.

General damages graph 486 includes mid band 490, lower range 492, andupper range 494. Mid band 490 corresponds to a most likely range forgeneral damages. Mid band 490 and ranges 492 and 494 may serve as visualaids to assist an adjuster in choosing amounts for settling an openclaim. In some embodiments, mid band 490 may be shaded, hatched,highlighted, or colored, or the like. Such indicators may provide anadditional visual cue to an adjuster for focusing on a most likelyamount or range. In certain embodiments, a display may include onlythose values within a particular band. For example, an x-y graph maydisplay only the portion of a curve associated with a mid-band, and notdisplay any values associated with points in the lower or upper ranges.

Summary portion 484 of display 480 includes numerical values of mostlikely amount and most likely range for general damages.

Although in the display shown in FIG. 10, graph portion 482 and summaryportion 484 relate to general damages, graphs may be directed to otheramounts. In certain embodiments, a display may include a graph andsummary for medicals instead of, or in addition, the graph and summaryfor general damages.

In certain embodiments, graphs and summary information are eachdisplayed on a separate screen. Switching between screens may beaccomplished by selecting a tab or by toggling between a graph screenand a summary screen. In certain embodiments, a display may includeother information associated with a matching claim set. For example, aHistory Dialog Window may include the following columns:

Date Run, Matched Cases, Lkly GD Amnt, Lkly GD High, Lkly GD Low, LklyMed Amt, Lkly Med Low, Lkly Med High

The ‘Lkly High/Low’ amounts may correspond to the Most Likely Low andHigh amounts. These amounts may appear on Summary, Graphs, Compare Withand/or Report screens.

In general damages graph 486 shown in FIG. 11, the likelihood (y-axis)includes scale of values 0 through 5. In other embodiments, values maybe shown without any specific numerical values. Thus, likelihood valuesmay be depicted graphically, relative to other likelihood values, ratherthan as an absolute value of likelihood.

In certain embodiments, an adjuster may be provided with amounts formatching precedent claims that are derived using two or more differentmethods. For example, an adjuster may consider a recommended settlementamount based on both a kernel density estimate for the matching claimsand a least squares analysis of the matching claims. FIG. 12 illustratesdisplaying summary amounts to a user based on a display mode selected bythe user. At 500, closed claims are identified that match an open claim.At 502, likelihood values are determined with respect to the matchingprecedent claims. At 504, amounts and ranges for use in settling theopen claim are determined based on the likelihood values for thematching precedent claims. At 506, one or more amounts and ranges aredetermined for settling the open claim based on least squares method.Amounts and ranges may be determined, for example, as described abovewith respect to FIG. 5. In one embodiment, a display based on leastsquares method may include a mid-zone amount and a mid-zone range.

At 508, a user may be prompted to select a display mode. If the userselects the likelihood display mode, summary amounts based on likelihoodare displayed at 510. If the user selects the least squares displaymode, summary amounts based on least squares are displayed at 512. Theselection of a display mode may be by toggle, tab, or other user input.In some embodiments, a default display mode may be established uponinstallation of a claims-matching program onto a computer system.

In certain embodiments, a user may simultaneously view amounts andgraphs based on more than one method. For example, a user maysimultaneously view amounts and graphs based on a maximum likelihoodmethod and amounts and graphs based on a least squares method.

In the embodiment shown in FIG. 12, amounts are automatically computedfor an open claim based on both likelihood and least squares methodsregardless of the mode selected by the user. In other embodiments, asystem may compute amounts only when the user selects a particular mode.For example, if the system default is to display likelihood values, thesystem might not calculate least squares values unless and until theuser selects a least squares display mode.

Adjusting General Damages Values Using Equalization Values

In some embodiments, general damages values for precedent claims areadjusted using predetermined equalization values to account for one ormore differences between an open claim and matching precedent claims.The equalization values may be derived from a set of closed claim dataand stored in a database when a system is first installed or configuredfor use process open claims. During processing of an open claim, theequalization values are retrieved from the database and used to adjustthe general damages values of matching claims. An adjuster may use theadjusted general damages values for the matching precedent claims asbasis for settling the open claim.

FIG. 13 illustrates determining equalization values based on definedequalization criteria for a system and processing open claims using thedetermined equalization values. Equalization criteria may be configuredor selected globally for all claims to be settled by an adjuster, groupof adjusters, or an FSO. In one embodiment, equalization criteria areselected or configured when a claims-matching program is installed on anFSO computer system. Equalization criteria are then applied to allclaims to be settled (or, alternately, to all claims that matchpredetermined criteria). At 600, equalization criteria are selected froma defined list. The defined list may be presented, for example, to aninstaller of a claims matching program when the program is installed.Equalization criteria may relate to various characteristics of a claimincluding locality, injury type, personal characteristics of a claimant,dominant injury, and claimant type. Equalization criteria may be basedon a single characteristic or a combination of two or morecharacteristics. Equalization criteria may be selected using drop-downmenus, check boxes, or similar methods.

At 602, equalization values are determined based on the selectedequalization criteria. The equalization values may be coefficientsderived from a set of closed claim data. In alternate embodiments, theequalization values may be expressed as factors or multipliers.Coefficient values will vary as a function of the characteristics of theclaims, such as jurisdiction, claim type, and/or secondary injury. Theequalization values may be calculated in a batch process. In oneembodiment, the batch process for determining the equalization values isrun when a claims-matching program is first installed. The equalizationvalues may be recalculated (e.g., by a subsequent batch process) atvarious times after the initial installation of a program. For example,the equalization values may be updated on a periodic basis, such asannually or quarterly.

In some embodiments, equalization values are determined based on theparticular customer's past claim data. For example, based on onecustomer's past data, baselined equalization values may produce anadjusted settlement amount for a claim in Louisiana that is 20% lessthan a similar claim in New York City, while, based on anothercustomer's past data, baselined equalization values may produce anadjusted settlement amount for a claim in Louisiana that is 22% lessthan a similar claim in New York City.

Beginning at 604, the system is placed into service to determine amountsfor use in processing open claims. It will be understood that once theequalization values are determined at 602 (such as at the time thesystem is installed), any number of open claims may be processed withoutrecalculating the equalization values. At 604, bodily injury data for anopen claim is entered into the system. At 606, one or more precedentclaims that match the open claim are identified by the system based onone or more characteristics of the open claim. At 608, a value of one ormore of the matching precedent claims is adjusted based on thepreviously determined baselined equalization values. For example, for anopen claim involving permanent impairment of a 20-year old male, thesystem may return an amount for a first matching closed claim settledfor a 25-year old male and a second matching closed claim settled for a30-year old male. Based on the baselined equalization values, the valuefor the closed claim relating to the 25-year old male may be increasedby 4%, and the value for the closed claim relating to the 30-year oldmale may be increased by 8%. As another example, a value for a closedclaim relating to a broken tibia might be adjusted upward for use insettling an open claim relating to a broken femur. At 610, an amount foruse in settling the open claim is determined based on the adjustedvalues for the closed claims. At 612, the amounts for settling the claimare displayed.

In one embodiment, equalization criteria includes jurisdiction, claimtype, and secondary injury (or a subset of one or more of thesecriteria). Other equalization criteria can be used, however. Forexample, in certain embodiments, equalization criteria include personalcharacteristics of the claimants. Examples of personal characteristicsto be used as equalization criteria include gender, age, or type ornature of the injury to the claimant, or type or nature of theimpairment to the claimant.

In one embodiment, equalization criteria include whether a claimant'sinjury is a combination injury or not. For example, one claim may relateto both a demonstrable and a soft tissue injury, while another claim mayrelate to only a soft tissue injury. A general damages value relating tothe soft tissue-only claim may be adjusted using baselined equalizationvalues to increase or decrease the value relative to a combinationinjury claim.

In an embodiment, equalization criteria include what a dominant injuryof a claim is. For example, if a claim arises from a case where thedominant injury is demonstrable, the general damages value may beadjusted using equalization values to increase or decrease the valuerelative to a claim arising from a case where the dominant injury is asoft-tissue injury.

In an embodiment, equalization criteria includes settlementcharacteristics for the claims. Examples of settlement characteristicsthat may form the basis for equalization include claim type (e.g.,whether a lawsuit has been filed), whether a claimant is represented byan attorney, or the identity of an attorney representing the claimant.In an embodiment, equalization criteria may include whether there is aparticular type of evidence available with respect to the accident. Forexample, equalization values may be based on whether data for theaccident is available from an electronic data recorder (EDR). In oneembodiment, equalization criteria may include whether EDR data for theaccident indicates that an injury was a low-impact injury. In certainembodiments, claims for which EDR data suggests fraud (e.g., falsewhiplash claims) may be adjusted or filtered out of the results.

In an embodiment, equalization criteria includes the locality of theclaim. A locality may be a country, state, or a region thereof. Incertain embodiments, a locality may be a sub-state locality (a portionof a state), such as a county, city, or zip code. For example, a generaldamages value for a matching claim in Orange County, California may beadjusted for use in settling an open claim in Los Angeles County,California, or Dade County, Florida based on past data from a Californiainsurer.

Determining Recommended Settlement Amounts by Adjusting Values Derivedfrom Matching Precedent Claims

In an embodiment, a recommended settlement amount is determined bycombining a value derived from precedent claims with one or moreadjustments for the pending claim. As used herein, a “pending claimadjustment” generally refers to an addition or subtraction based on oneor more amounts associated with the pending claim. Pending claimadjustments can include any adjustment for the actual claim beingsettled. Examples of pending claim adjustments include specials,disfigurement, offsets, medical expenses (e.g., incurred expenses orexpected expenses), wages (e.g., actual lost wages or expected lostwages), or a combination thereof. Thus, a recommended settlement may becalculated as follows:

Adjusted General Damages Amount precedents+Adjustments pendingclaim=Adjusted Recommended Settlement Amount

In some embodiments, recommended settlement ranges may be determined ina similar manner as the recommended settlement amounts.

FIG. 14 illustrates determining recommended settlement amounts andranges with adjustments to adjusted general damages values derived frommatching precedent claims. At 700, precedent claims that match an openclaim are identified. At 702, a likelihood value is determined withrespect to each of the matching precedent claims. At 704, likelihoodvalues associated with matching precedent claims are displayed.

At 706, an adjusted general damages amount for the open claim isdetermined based on the likelihood values for the matching precedentclaims. At 708, a range of adjusted general damages amounts isdetermined for the open claim based on the likelihood values for thematching precedent claims. At 710 and 712, pending claim adjustments aremade to an adjusted general damages amount and general damages range forthe open claim, respectively. The pending claim adjustments may be madeautomatically, for example, by an FSO computer system. At 714 and 716, amost likely settlement amount and most likely settlement range for theopen claim are determined. At 718 and 720, computed amounts and rangesare displayed to a user.

In the embodiment shown in FIG. 14, the general damages amounts andranges are determined based on likelihood values for the matching closedclaims (see 702, 706, and 708). In other embodiments the general damagesamounts and ranges may be determined from other methods, such as from amid-zone calculation based on a least squares method.

In one embodiment, an “Adjusted Recommended Payout” amounts arecalculated after the matching process has been completed and displayedon the Summary tab of the screen. The recommended payout amounts may bea combination of the adjusted general damages amounts of catalog claims(e.g., similar past claims) brought back in the matching process and thespecials, offsets, adjustments, and disfigurement of the pending claim(i.e. the claim currently being entered into the system and adjusted).An example determination is as follows:

Adjusted  Settled  GD  amount  of  catalog  claim + Disfigurement + Medicals  Incurred + Medicals  Expected − Medical  Offset + Wages  Incurred + Wages  Expected − Wages  Offset − Comparative  Negligence  (multiplied  as  a  percentage  of  the  subtotal  amount  and  then  subtracted) − Contribution  Percent  Amount  (multiplied  as  a  percentage  of  the  subtotal  amount  and  then  subtracted)  OR  Contribution  Dollars − Other  Offsets = Recommended  Settlement  Amount  

As used in the preceding equation, “Adjusted Settled GD amount ofcatalog claim” may exclude specials and disfigurement, but include otheroffsets. The above formula may be applied to settlement values andranges. For example, the above formula may be applied to a most likelysettlement amount and a most likely settlement range.

Least Squares Display

For a least squares display, the formula described above for RecommendedSettlement Amount may be applied to the final high, average, and lowamounts that are displayed in the Adjusted Generals column based on aleast squares method. After the Recommended Settlement amounts have beencalculated for the claims catalog, those amounts may be displayed in theRecommended Settlement column. The amounts can be calculated each timethe user navigates to the screen if the specials, offsets, ordisfigurement have been updated since the previous re-run. Any amountsthat are calculated to be less than zero may be displayed as a ‘$0’ inthis column (i.e. negative amounts are not displayed). The following isan example display of values based on a least squares method:

Adjusted General Damages: Recommended Settlement: High: $5,500 High:$7,500 Average: $3,500 Average: $5,500 Low: $2,000 Low: $4,000The following is an example display of adjustments for a pending claim:

Specials/Offsets and Disfigurement for the Current Claim Disfigurement:$5,000 Net Medicals $2,000 Net Wages $1,400 Negligence Percent: 60%Contribution Percent: 40% Contribution Dollars: Other Offsets: $1,000Total:

Likelihood Display

For a likelihood display, the display may contain fields named “MostLikely Settlement Amount” and “Most Likely Settlement Range” and appearin the corresponding locations as the current amount fields located inthe Adjusted Generals section. The amounts can be calculated and storedeach time the user navigates to the screen if the specials, offsets, ordisfigurement have been updated since the previous re-run. Any amountsthat are calculated to be less than zero may be displayed as a ‘$0’ inthis column (i.e. we will not display negative amounts). The followingis an example display of values based on maximum likelihood:

Adjusted Generals Most Likely Amount: $4,290 Most Likely Range:$4,000-4,700 Recommended Settlement Most Likely Settlement Amount:$7,290 Most Likely Settlement Range: $7,000-7,700

Evaluating Effectiveness of Claims Evaluation, Assessment, andSettlement Processes

In the discussion above with respect to FIGS. 2, 6, and 7, a system isused for settling outstanding claims (a “production” environment). Eachcandidate claim is an open claim for which an estimate of value isdesired for purposes of settling the claim. In support of this process,the system provides an adjuster with access to data on closed claimsthat match the open claim. In another embodiment, a claims-matchingprocess is used to evaluate a claim estimation, negotiation andresolution process that has already been used by a company (i.e., a post“production” environment). In this embodiment, each closed claim may betreated as a candidate claim and compared with other closed claims.Mathematical models may be used to determine the effectiveness of theprocess that has been used. For example, the system may be used toquantify how consistent a claim estimation and settlement process was.Such determinations may be used to guide process improvements and/orprovide benefit studies on proposed or anticipated process changes.

In an embodiment, an evaluation of a claims settlement process isperformed using cross comparisons of an insurer's closed claim data forbodily injury claims. The data may reflect hundreds or thousands ofclosed claims. FIG. 15 illustrates determining an effectiveness of aprocess using a closed claim-to-closed claim comparison according to oneembodiment. At 360, a set of closed claim data is provided. In certainembodiments, an insurer's closed claim data may be initially scrubbed toremove data that might skew the results, such as claims that haveinvalid or missing information. The closed claim data may be for adefined period (e.g., the preceding 3 years). The closed claim data maybe limited by other attributes, such a jurisdiction, claim type, ordominant injury.

At 362, precedent claims are identified for a closed claim in a definedset of claims. Each closed claim in the data set is considered acandidate claim when it is used as the claim at issue. The claim datafor each candidate claim is used when searching for precedents (e.g.,matches) of that candidate claim. In some embodiments, a claims matchingprocess is performed as described above with respect to FIG. 2, exceptthat each candidate claim is a closed claim instead of an open claim.

In certain embodiments, the system automatically excludes precedentclaims from the set of matches if they exceed a defined amount ofvariation from some attribute of the set of precedent claims. Forexample, the system may automatically exclude precedent claims from theset of matches if they are greater than two standard deviations above orbelow the mean of the set of matches. Approximately 95 percent of allmatching claims are within two standard deviations of the mean of allsuch matches to the candidate claim.

At 364, a representative value is determined for the precedent claimsassociated with the candidate claim. The representative value may bebased on a statistical value such as mean, median, or mid-zone value ofthe precedent claims.

At 366, if there are additional candidate claims, the system repeats thesequence of precedent claim identification (362) and determination of arepresentative value (364) for each of the candidate claims.

At 368, one or more representative values of the precedent closed claimsare compared with one or more values of the candidate closed claims. Forexample, the comparison may include computing a difference between therepresentative value (e.g., mean, median, or mid-zone value) of theprecedent claims and the value of the candidate closed claims.

At 370, consistency of the claims estimation and settlement process isevaluated. The evaluation may be based on a comparison of the values ofthe candidate closed claims with representative values of the similarclaims. For example, a small aggregate deviation between the values ofthe candidate claims and the representative values of the associatedsets of precedent claims may indicate that the process used to arrive atthe values of the candidate claims produces consistent results.Conversely, a large aggregate deviation between the values of thecandidate claims and the representative values of the associated sets ofprecedent claims may indicate that the process used to arrive at thevalues of the candidate claims produces inconsistent results.

Various methods and approaches may be used to determine representativevalue of similar claims. The mathematical models used may rely, in somecases, on assumptions about how adjusters are influenced by a resultinglist of matches. For example, human tendency may result in adjustersactually looking at clusters, mid-points, and averages similar to themodels described herein. In addition, adjuster decisions may be shapedbased on a particular company's policies and procedures. In oneembodiment, determining a representative value may include kerneldensity estimation. In another embodiment, determining a representativevalue may include maximum likelihood estimation.

FIG. 16 illustrates evaluation of a claim estimation and settlementprocess that includes determining differences between the generaldamages values for candidate closed claims and general damages valuesfor similar closed claims according to one embodiment. At 380, for eachcandidate claim in a closed claim data set, claims in the data set thatare similar to a candidate claim are identified based on characteristicsof the candidate claim. Although the entire data set might includethousands of claims, the mathematical modeling is performed on eachclaim separately, treating each claim as the candidate claim. Eachcandidate claim will have a subset of precedent matches from the otherclaims. Therefore, the relevant data set size is represented by thenumber of precedent claims matched to the candidate claim. Each data setcould be one precedent claim or many precedent claims.

At 382, a representative general damages value is determined for the setof precedent claims associated with each of the candidate claims. Therepresentative general damages value may be based on a statistical valuefor the entire set, or for a subset, of the similar claims. In someembodiments, the mathematical analysis is successively performed usingmodels and methods of increased complexity and sophistication.Initially, simple measures, such as median and mean, which do notrequire assumptions about the underlying set of matched general damages,may be used. The median is the number that splits the ordered set ofprecedent claims essentially in half. By using the median, effects ofoutliers are minimized without having to exclude any claims from thecalculation. The mean is the average of all precedent matches. Themedian and mean are calculated using the set of precedent matches foreach closed candidate claim. Once the median and mean are calculated,they are compared to the actual total general damages for the candidateclosed claim.

At 384, if there are additional candidate claims, the system repeats thestep of precedent claim identification (380) and calculation of arepresentative value (382) for each of the candidate claims.

At 386, a total accumulated general damages value for the candidateclaims is determined. The total accumulated general damages value may bethe sum of the general damages values for all the candidate claims.

At 388, a total accumulated representative general damages value for thesets of similar claims associated with the candidate claims isdetermined. The total representative general damages value may be thesum of the representative general damages value determined for the setsof precedent claims.

At 390, for the complete data set of matches, the total accumulateddifference (variance) between each candidate claim's general damagesvalue and its corresponding representative general damages value (e.g.,mean, median, or mid-zone) is determined for all candidate closedclaims. The total accumulated difference may be the difference betweenthe sum of all the general damages values of the candidate claims andthe sum of the representative general damages value for the associatedsets of precedent claims. In an alternate embodiment, a difference isfirst computed between the value for each candidate claim and therepresentative value for the precedent claims, and then the accumulateddifference is determined by taking the sum of these differences.

At 392, an impact percentage is calculated based on the totalaccumulated difference. The impact percentage may be determined bydividing the total accumulated difference by the total accumulatedgeneral damages for the candidate claims. The impact percentage may beexpressed in the following formula:

$\frac{\begin{matrix}{{the}\mspace{14mu} {difference}\mspace{14mu} {between}\mspace{14mu} {the}\mspace{14mu} {total}\mspace{14mu} {general}\mspace{14mu} {damages}\mspace{14mu} {value}\mspace{14mu} {for}\mspace{14mu} {the}} \\{{{candidate}\mspace{14mu} {claims}\mspace{14mu} {and}\mspace{14mu} {total}\mspace{14mu} {representative}\mspace{14mu} {general}\mspace{14mu} {damages}}\;} \\{{value}\mspace{14mu} {for}\mspace{14mu} {the}\mspace{14mu} {sets}\mspace{14mu} {of}\mspace{14mu} {similar}\mspace{14mu} {claims}}\end{matrix}}{\begin{matrix}{{total}\mspace{14mu} {general}\mspace{14mu} {damages}\mspace{14mu} {value}\mspace{14mu} {for}\mspace{14mu} {two}\mspace{14mu} {or}\mspace{14mu} {more}\mspace{14mu} {of}\mspace{14mu} {the}} \\{{candidate}\mspace{14mu} {claims}}\end{matrix}}*100\%$

In some cases, the impact percentage may be used as a measure ofconsistency of the estimation and settlement process (with relativelylarger impact percentage reflecting greater inconsistency in theestimation and settlement process). For example, an impact percentageless than 2% may indicate that the process for establishing a value ofthe candidate claims was relatively consistent in producing values,while an impact percentage of greater than 10% may indicate that theprocess was relatively inconsistent in producing values. Impactpercentages may be used in benefit studies to project the impact ofmaking a process change or improvement. For example, the impactpercentages may be used to project a potential improvement to an insurerfrom implementing a new system and/or methodologies for evaluating andsettling open claims.

FIG. 17 illustrates a simple example of results for a closed claimmathematical analysis. For the sake of simplicity for illustrativepurposes, only two candidate claims are included in the set. A closedclaim evaluation might, however, include any number of candidate claims,and might include hundreds or thousands of candidate claims.

In the example shown in FIG. 17, information is provided for each of thecandidate claims, including identification (ID), claim type,jurisdiction, dominant injury (e.g., soft tissue or demonstrable), andvalue. The value for each candidate claim may be a general damages valuefor the claim as determined by a claim adjuster during the evaluationand settlement of the claim. A set of matching closed claims is listedfor each of the candidate closed claims. Each of the matching claimsincludes a corresponding value. For each candidate claim, the matchingclaims may be grouped into zones (e.g., low, mid, high). A mean, amedian, and a mid-zone average are computed for each set of similarclaims. In the example shown in FIG. 17, the mid-zone average is anunweighted average of the mid-zone claims (i.e., claims O, P, Q, and Rfor candidate claim 1 and claims W, X, and Y for candidate 2). In otherembodiments, a mid-zone average may be a weighted average. For example,each of claims O, P, Q, and R may each be given a different weightdepending on their degree of similarity to candidate claim 1.

The total of each value category is accumulated to yield the totalassociated with all candidate claims. For each representative value, thedifference between the total representative value and the total value iscalculated. Based on the difference for each representative value, theimpact percentage is determined.

In some embodiments, an impact is determined for a subset of aninsurer's closed claim data that meets certain criteria. For example, animpact may be determined for only the claims having a certain claimtype, jurisdiction, or dominant injury. In one embodiment, claim typesinclude: unrepresented, unlitigated, and suit. “Unrepresented” are thoseclaims without attorney representation. “Unlitigated” are those claimswith attorney representation, but no suit has been filed. “Suit” arethose claims in which some type of suit has been filed, but notnecessarily a jury verdict outcome.

As is reflected in FIG. 17 above, a matching process may produce adifferent number of matches for each candidate claim. For example,candidate ID 1 has 8 matches, while candidate ID 2 has 5 matches. Thefrequency of the number of matching claims may be plotted for thecandidate claims. The results may be presented to the user is graphicalor textual format.

FIG. 18 illustrates a column chart for reporting the matching frequencyfor a claim set according to one embodiment. In this column chart, thex-axis represents the number of matching claims for a candidate and they-axis represents the number of candidate claims having a given numberof matching claims. Thus, the legend at the base of each columnrepresents a number of matching claims for a candidate. The height ofthe column indicates the total number of candidate claims in the claimset with that number of matches. For example, there were 800 candidateclaims in the set for which 6 matching claims were identified. In someembodiments, other statistical information, such as mean and standarddeviation may be reported, presented and/or used in evaluating aneffectiveness of a claims assessment process.

Identifying Similar Claims

Every injury has its own treatment modality. Finding similar claims maytherefore take this into consideration. For example, soft tissue spinalinjuries are treated therapeutically. While their treatment details canvary they are all prima facie the same injury, distinguished by theirtreatment, whereas demonstrable injuries are at face value not similarinjuries. For example, a fractured femur and a contusion to the lowerleg are completely dissimilar.

Whether a claim will use the soft tissue spine matching or thedemonstrable matching component may be an important consideration.

In various embodiments, similar claims may be found using the followingsteps:

-   -   1. Identify whether the major injury is predominantly a soft        tissue spinal injury type or a demonstrable injury        If soft tissue spinal injury:    -   1. Search the settled claim database for claims that have at        least one of the soft tissue spine injuries the current claim        contains    -   2. Filter the claims whose medical attributes are not within        certain pre-defined tolerances of the attributes of the current        claim    -   3. From the matches display a subset of claims which have        attributes closest to the current        If demonstrable injury:    -   1. Retrieve the pain and suffering severities for all the        injuries, treatments and complications which are contained in        the current claim    -   2. Identify all the major body parts injured for the current        claim    -   3. Identify the most injured major body part    -   4. Find the dominant medical feature (injury, treatment or        complication, or combination of them)    -   5. Search the settled claims database for all of the claims        having the same dominant medical feature    -   6. From the matches display a subset of claims which have the        closest attributes to the current claim

Deciding Whether a Claim is Demonstrable or not

A claim may be defined to be predominantly demonstrable if it falls intoany of the following categories:

1. It has no soft tissue spinal injuries

2. It contains an invasive medical procedure (diagnostic or surgical)

3. It is one of the following injuries

-   -   a. Amputation    -   b. Closed Fracture    -   c. Open fracture    -   d. Dislocation    -   e. Fracture dislocation    -   f. Crush injury    -   g. Internal throat injuries    -   h. Intervertebral disc herniations or ruptures    -   i. Intra-abdominal injuries    -   j. Intra-pelvic injuries    -   k. Intra-thoracic injuries    -   l. Ligament injuries (but not a shoulder ligament injury)

4. It has any of the following, but no soft tissue spine injuries

-   -   a. Lacerations    -   b. Concussion    -   c. Contusions    -   d. Superficial injuries    -   e. Sprain strain injuries

Shoulder ligament injuries, lacerations, concussion, contusions,superficial injuries and sprain strain injuries may not be indicators,by themselves, of whether a case is demonstrable or not. For instance,there are many whiplash claims that also include shoulder ligamentinjuries. In these cases the shoulder injuries are not treated, otherthan as part of the whiplash injury by therapeutic treatment. If theshoulder ligament injury were treated surgically then the case would beconsidered demonstrable, as per rule 3 above).

Deciding Whether a Claim has Only Trivial Injuries

Trivial injuries are defined as the injuries for which no matchingpriority rules exist. Injuries such as contusions, untreatedlacerations, and superficial injuries are trivial injuries.

If a claim contains only trivial injuries then the system may findmatches for the most significant of the trivial injuries, as defined bythe injury hierarchy, set out under “Injury Hierarchy” in the Sectionexplaining rule priority considerations.

If a claim contains both only trivial injuries and a soft tissue spineinjury then the system may use the presence of the trivial injuries asmatching criteria if the injury filter is set to “tight”. This isexplained in the injury section within “Filters” described below.

Matching for Soft Tissue Spine

In an embodiment, the two broad classes of claim information that willbe used in the matching are treatment duration and treatment level,there being a correlation between treatment duration and treatmentlevel. Treatment time defines injury stabilization time or the timetaken for an injury to reach maximum improvement. Treatment level caninvolve multiple types of therapeutic treatment. For instance, this canbe any combination of chiropractic, physical therapy, other therapy, GPconsultation and specialist doctor consultation. Other treatment caninvolve various forms of spinal immobilization and prescribedmedication.

Matching may involve setting some bounds around the values that areinherent in the current claim, in order to find claims that havesimilar, but not necessarily exactly the same values. In one embodiment,the criteria used for matching similar claims is as described in thetables below.

Treatment Time Percentage Variation Percentage Variation ActualTreatment Days Below Above 0 100% 100% 30 25% 33% 1080 33% 50%The table above may be based on a piecewise linear function approach.For example, a claim where the treatment time was 30 days will beaddressed in the following manner. The 30 days treatment time is locatedin the first column, it is the second entry. The bounds then become from30 days minus 25%, this being approximately 23 days, to 30 days plus33%, this being approximately 37 days. Thus initially claims are lookedfor that had treatment times of 23 to 37 days, in this case. Fortreatment times which do not fall exactly on a value in the firstcolumn, which will be the case the vast majority of the time, apiecewise linear extrapolation may be used to determine the appropriateintermediate value. A worked example is contained for “Treatment Level”below. Exactly the same formula would be used.

Treatment Level GP Treatment Consultations Actual GP Visits GP VisitsFrom GP Visits To 0 0 1 1 1 2 2 1 3 5 4 7 10 7 14 20 15 30 50 31 70In the table above the second and third columns define the low and highbound of GP visits that will be searched for. For example, if thecurrent claim had 5 actual GP visits search would be searched for claimsthat had between 4 and 7 GP visits (these being the values from thesecond and third columns for the fourth row, which has the 5 GP visitsin the first column).Intermediate values for GP visits, such as 4 visits, result in piecewiselinear extrapolation of the 5 second and third columns to derive the lowand high bound.Piecewise linear extrapolation may be defined as:

$y = {\frac{\left( {x - x_{1}} \right)\left( {y_{2} - y_{1}} \right)}{\left( {x_{2} - x_{1}} \right)} + y_{1}}$

where y is the extrapolated value; x is the number of GP visits; x₁ isthe value from the first column which is less than x; x₂ is the valuefrom the first column which is greater than x; y₁ is the value fromeither the second or third columns (depending on whether we arepredicting the lower or upper bound) which corresponds to the x₁ valuefrom the first column; and similarly y₂ corresponds with x₂.Using 4 GP visits as the actual value results in bounds of 3 to 5.66667,which are rounded to 3 to 6.

Specialist Treatment Consultations Actual Specialist Visits SpecialistVisits From Specialist Visits To 0 0 0 1 0 2 2 1 3 5 4 7 10 7 14 20 1530 50 31 70The tables for GP and specialist are almost identical, except that ifthe actual specialist visits is zero then only claims with zerospecialist visits will be matched. This is different from the treatmentof GP visits, where if the actual visits are zero claims with zero or 1GP visits will be matched.Both the GP and specialist tables differ from the therapeutic treatmenttables below, in that for the higher values in column 1 thecorresponding bands (columns 2 and 3) are broader upwards more thandownwards. For example, for 20 GP visits the band is between 15 and 30visits, whereas for therapeutic treatment it is 15 to 25. Even fortherapeutic treatment of 70 visits the band is equally distributed,being from 55 to 85—a difference of 15 either side. For the GP andspecialist it is regarded that there comes a point where additionaltreatment no longer impresses as to the severity of the injury, and itsuggestive of over-servicing. For this reason the band is larger on thehigh side.In some embodiments, the above table entries can be altered to reflect aparticular company's experience or as new trends emerge.

Chiropractic Treatment Visits Actual Chiropractic Visits ChiropracticVisits From Chiropractic Visits To 0 0 2 2 1 4 5 3 8 10 7 14 20 15 25 4030 50 70 55 85 100 80 120In a similar manner to the previous table, this table defines the lowand high bounds for chiropractic treatment used in matching. Physicaltherapy and other therapy are processed in the same manner using therespective tables below. However, each therapeutic treatment type isused distinctly in the matching process, and matched claims must satisfyall the derived bounds. For example, if the current claim had 10chiropractic visits and 10 physical therapy visits then matched claimsmust have between 7 and 14 chiropractic visits and also between 7 and 14physical therapy visits.

Physical Therapy Treatment Visits Actual Physical Therapy PhysicalTherapy Visits Physical Therapy Visits From Visits To 0 0 2 2 1 4 5 3 810 7 14 20 15 25 40 30 50 70 55 85 100 80 120

Other Therapy Treatment Visits Actual Other Other Therapy Therapy VisitsVisits From Other Therapy Visits To 0 0 2 2 1 4 5 3 8 10 7 14 20 15 2540 30 50 70 55 85 100 80 120Other therapy includes treatment given by practitioners of osteopathy,naturopathy, homeopathy or other “alternative medical practices” such asacupuncture, herbal medicine, faith healing, massage or any othernon-orthodox therapeutic practices.The tables have different values associated even with the same actualobserved value. In other words, if our claim has no GP visits the boundsbecome up to 1 GP visit. The difference between none and one GP visitmay not be significant. However, the difference between a claim forwhich a specialist opinion was sought and one where it was not requiredhas more significance as an indicator of severity, simply because of thefact that a specialist opinion was required. Most soft tissue injurieswould not involve a specialist referral.

In a similar manner to the demonstrable injury matching processdescribed below, a number of filters are also used to refine the matchresults. The use of these filters is described in the Section “Filters”below.

Matching Similarity for Demonstrable Injuries

In some embodiments, matching similar cases may include, in the firstinstance, matching similar injuries. Injuries as defined by the programinclude traumatic amputations, fracture dislocations, dislocations,fractures, intra-abdominal injuries, intra-thoracic injuries,intra-pelvic injuries, vertebral disc injuries, ligament injuries,lacerations, sprains and strains and trivial injuries such as contusionsand superficial injuries.

Demonstrable injuries rarely occur in isolation or to only one bodypart, and often involve multiple trauma to multiple body parts. Matchingsimilar cases in these instances may include determining what thedominant injury (or injuries) is, or in other words, what major bodypart was most severely injured. Determining what major body part isinjured is not based only on the type of injury suffered. The overallseverity of the trauma is not just the injury suffered but can also beinfluenced by the treatment and often the complications that might arisefrom the injury.

As an example, consider a case involving a fractured skull, requiringcraniotomy for an intracranial hematoma. A fractured skull is not aninsignificant injury; but an intracranial hematoma is both lifethreatening and potentially can lead to residual brain damage; whichrequired an invasive operative procedure to drain the hematoma(craniotomy). A fractured skull would not generally require anyoperative treatment. In this case the craniotomy alters the nature ofthe case, making it a more severe head injury. The complication of theintracranial hematoma transcends both the initial injury and theoperative treatment, and becomes the dominant medical feature of thisclaim. Determining the most severely injured body part therefore takesinto account all three of these considerations—injuries, treatments andcomplications, or a combination of these.

The dominant medical feature of a case can be specified by the adjusterusing the system's user interface, or failing this, can be determined bythe system.

Establishing the Most Injured Body Part

In some embodiments, if the user has not specified the dominant medicalfeature of a case then the system can perform this function. In order todo this the system:

-   -   Retrieves all the medical facts about the case, the injuries,        treatments, complications and impairments    -   Accesses its own database tables to retrieve medical attributes        corresponding to these case medical facts    -   Using its own algorithms it derives the overall severity of each        major body part. The major body parts include the head, chest,        abdomen, pelvic area, the spine, arms and legs.    -   Determining the dominant medical feature of the most injured        body part

Retrieving Medical Codes

Each case can have any number of medical attributes associated with it.These can be a number of injuries, treatments and complications, in anycombination. For each of these instances there is a correspondingcharacter code (there is a seventh character denoting sidedness), whichis constrained to be from a list of treatment, or complication codespredefined with each injury code tracked by the system.

In certain embodiments, predefined treatment and complication codes maybe derived from a series of mappings within the system. Injury may bemapped to treatment, injury may be mapped to complication, andcomplication may be mapped to treatment. For each injury code, thesystem may have a list of treatments the injury may require, these aresorted as “expected” and “possible” treatments. For example if theinjury were an open fracture of the tibia, the treatment list mightcontain:

-   -   Amputation or re-amputation    -   Osteotomy    -   Limb shortening or lengthening procedures    -   Arthroplasty    -   Arthrodesis    -   Open reduction of fracture    -   External fixation    -   Traction    -   Closed reduction of fracture    -   Immobilization    -   Removal of internal fixation device    -   Physical therapy    -   Debridement of open fracture site    -   Walking aids    -   Diagnostic studies    -   Prescribed medication.        In addition, the list can include treatments for potential        complications which will vary depending on the type of        complication that occurred. This might include such procedures        as fasciotomy, osteoarthrotomy, nerve or vascular repair.        Medical procedures are considered only as past and future        procedures, there is no notion of initial treatment or        subsequent treatment, and these are considered simply as past        treatment. Similarly, for each injury code, the system can have        a list of potential complications that might arise from the        injury. In the case of our fractured tibia this would include:    -   Associated vascular    -   Associated nerve injury    -   Avascular necrosis    -   Osteomyelitis    -   Osteoarthritis    -   Compartment syndrome    -   Deep vein thrombosis    -   Nonunion    -   Malunion    -   Delayed union.        Complication and treatment mapping may be derived from medical        references including:    -   1. Apley's System of Orthopaedics and Fractures—6^(th) Edition    -   2. Attorney's Textbook of Medicine: Manual of Traumatic        Injuries—Volumes 1-3    -   3. Attorney's Textbook of Medicine—3^(rd) Edition—Volumes 1-18    -   4. Vertebral Musculoskeletal Disorders—Corrigan & Maitland    -   5. Essentials of Surgery—Scientific Principles and        Practice—Lippincott-Raven publication    -   6. Current Surgical Diagnosis & Treatment—10^(th)        Edition—Appleton & Lange publication    -   7. Rehabilitation Medicine—Delisa Gans—3^(rd)        Edition—Lippincott-Raven publication    -   8. The Disability Advisor—3^(rd) Edition—Pressley Reed

Medical Severity Attributes of Medical Codes

After the medical codes are entered against a case, a table may beaccessed which defines a number of attributes for each medical code. Insome embodiments, the pain and suffering severity scale is used toderive overall medical severity for each injured body part, given themedical facts regarding the case being considered.

A pain and suffering severity scale can represent relative severitybetween injuries, treatments and complications respectively. Theseverity applied may be in isolation to the particular injury, treatmentor complication it is applied to. For example the severity applied to anopen fracture of the femur can be for the relative trauma of thefracture alone, and not include the treatment or any otherconsiderations. Conversely the relative severity applied to an openreduction of the femur might not take into account the trauma for thefracture. Also, the scale may not include severity for impliedimpairment. For example procedures such as amputation and arthrodesisleave permanent impairments but these may be ignored in the assignedvalue.

The pain and suffering severity scale may be refined through acalibration process described below.

Calculating Major Body Part Relative Pain and Suffering Severity

In an embodiment, agglomeration algorithms are used to derive a combinedvalue for a body part when more than one medical code is present. Forexample, if a case consisted of a fractured humerus and a fracturedscaphoid, both being to the same arm, then the agglomeration algorithmcan derive an overall value for the arm in question, comprising bothinjuries. The system can do this for every body part described above.

The determination of the combined value may not be a simple summation ofthe medical codes. Doing so would result in unconstrained total values.For example, even if a case involves a fracture of the middle finger,which on average settles for $5,000, this does not mean that a caseinvolving three fractured fingers should settle for $15,000. Forexample, the proximity of the fingers may obviate the combined valuebeing three times the value of one, thus the value for the three-fingerinjury should be less than three times that of the one-finger injury.

As injuries become less proximal to each other then combined value mayincrease, towards the sum of the value of the individual injuries.

Deriving the Dominant Medical Feature

In some embodiments, a set of rules may be utilized, one set for eachmajor body part. Each rule detects a particular medical feature. Forexample, one rule, within the leg detects a femur fracture withosteomyelitis, another with avascular necrosis, yet another for nonunionof the femur.

If only one body part was injured then its related rules may be run todetermine the primary medical features and which cases to search for.Example rules are described below for each body part. If more than onebody part was injured then the rules may be run for the most injuredbody part only. The “most injured” body part may be the body part withthe highest combined value on the pain and suffering severity scale(described above). All the medical codes present in the case may bevisible to all the rules, thus rules can reference medical codesbelonging to this body part as well as ones that are systemic (affectingthe whole body).

On the other hand, if the user has nominated one or more dominantmedical features then the rules may be run which correspond to bodyparts representing the dominant medical features. For example, if theuser had nominated a fractured tibia and a fractured humerus asdominant, then the rules may be run for the leg and those for the armrespectively. In running these rules the system may be restricted toseeing only the dominant medical features nominated by the user—othermedical codes which may be present on the case but not made dominantwill not be considered by the rules.

Cases can have a number of medical features, even for the same bodypart. This can result in more than one rule potentially beingconsidered. For example, in a case where there is a fractured humeruswith delayed union and an uncomplicated fractured thumb, then twodifferent rules could be executed—one for the humeral fracture and itscomplication and another for the thumb. In these cases rule prioritydetermines which will have precedence when it come to searching formatching cases. In this example it will be the fractured humerus withdelayed union that will have precedence owing to the higher priorityassigned to its rule. In one embodiment, the rule priorities are asdefined in the section “Rule Prioritization Considerations” below.

Rule Prioritization Considerations

In prioritizing the rules a number of medical considerations may betaken into account. These include:

-   -   The hierarchy of injury    -   The hierarchy of complications    -   The hierarchy of treatments    -   Exceptions for some injuries    -   Exceptions involving multiple medical features        Injury hierarchy may be derived from medical texts and        literature and a Judicial Publication. Reference sources may        include:    -   1. The Judicial Studies Board “Guidelines for the Assessment of        General Damages in Personal Injury Cases—4^(th)        Edition—published by Blackstone Press    -   2. Fractures and Dislocations—Apley's System of Orthopaedics and        Fractures—6^(th) Edition    -   3. Attorney's Textbook of Medicine: Manual of Traumatic        Injuries—Volumes 1-3—a Matthew Bender publication    -   4. Attorneys Textbook of Medicine—3^(rd) Edition—Volumes        1-18—Matthew Bender publication    -   5. Vertebral Musculoskeletal Disorders—Corrigan & Maitland    -   6. Essentials of Surgery—Scientific Principles and        Practice—Lippincott-Raven publication    -   7. Current Surgical Diagnosis & Treatment—10^(th)        Edition—Appleton & Lange publication    -   8. American Medical Associations “Guides to the Evaluation of        Permanent Impairment—5^(th) Edition    -   9. Rehabilitation Medicine—Delisa Gans—3^(rd)        Edition—Lippincott-Raven publication        In general the hierarchy of injury may be:

1. Loss of vision

2. Major amputations

3. Fracture dislocations to major joints

4. Fractures

5. Intra-abdominal injuries

6. Intra-pelvic injuries

7. Intra-thoracic injuries

8. Dislocations

9. Ligament and tendon injuries

10. Sprain and strain injuries

11. Lacerations

12. Contusions

13. Superficial injuries

Within each of these injury groups there may also exist anotherhierarchy. For example, for fractures clearly a fractured femur is muchmore serious than fractured toe. Similarly, the removal of a kidney ismuch more serious than the removal of a gallbladder. Of course, afractured toe is a trivial injury compared to any significantintra-abdominal injury. Therefore the injury hierarchy when applied tothe body as a whole is not a strict one, but only a guide to theplacement of different injuries in a pain and suffering medical severityscale. When applied to a body part this injury hierarchy is moreconstant though still with exceptions. In the arm for example, generallyamputations would precede fracture dislocations and fractures anddislocations, which would precede ligament injuries, sprains strains andcontusions and superficial injuries.

Injury complications can be either localized or systemic, and likeinjury type has a hierarchy which is along the following:

-   -   1. Life threatening, such as septicemia, peritonitis or        pneumonia    -   2. Brain complications such as intracranial hematoma—subdural,        subarachnoid or epidural hematoma, cerebral edema or        posttraumatic epilepsy    -   3. Cranial nerve involvement such as vertigo, tinnitus or loss        of smell and taste    -   4. Vascular complications such as crush syndrome, hypovolemic        shock, deep vein thrombosis, compartment syndrome or hemorrhage    -   5. Thoracic complications such as pneumothorax, hemothorax,        pneumothorax or pleural edema    -   6. Treatment complications such as fistula or adhesions    -   7. Bone complications such as osteomyelitis, avascular necrosis,        bony union difficulties or limb deformities    -   8. Joint complications such as osteoarthritis, synovitis, joint        stiffness or joint laxity    -   9. Pelvic complications such as hematuria, ureteral or urethral        strictures    -   10. Localized infections        Although a hierarchy exists, it may not be strictly followed in        all cases. For example, osteoarthritis of the hip is not the        same as osteoarthritis of the little finger.        In one embodiment, a treatment hierarchy includes, but is not        limited to:

1. Amputation

2. Major chest surgery such as thoracotomy

3. Removal of the eye

4. Organ removal such as kidney or spleen

5. Other abdominal surgery

6. Pelvic surgery

7. Skull procedures such as craniotomy or craniectomy

8. Joint surgery such as spinal fusion, arthrodesis or arthroplasty

9. Bone surgery such as fracture reductions, sequestrectomy or osteotomy

10. Ligament and tendon repairs

11. Vascular repair

12. Fascia repair

The above hierarchy is a guide as to the severity of treatments. Forinstance the amputation of the arm at the shoulder is far more severethan the amputation of the little finger. Accordingly there will beconsiderable overlap between treatments in the hierarchy in terms ofwhere medical severities could be allocated.Some injuries can be exceptional and therefore not be close to others oftheir kind in the hierarchy. For instance, a true dislocation of theknee (a tibiofemoral dislocation) is an orthopedic emergency, with theloss of the limb possible unless it is treated promptly andprofessionally. Even then the outcome will be guarded. Within the sameinjury category, dislocations, will be hip dislocations for instance.These latter dislocations do not present the same orthopedic emergencynor are they likely to have the same medical outcome. So in this case,dislocations of the knee would be regarded as the most severe form ofdislocation and would rate as a more severe injury in the overallhierarchy of injury than it would have otherwise.

There are also instances where a combination of medical features canhave significant implications for the matching process. For instance, alaceration of the upper arm requiring nerve repair implies that a 3^(rd)degree peripheral injury is present. Such nerve injuries can lead tosignificant impairment of the limb. On the other hand, a laceration tothe upper arm with vascular repair is also a significant injury but isunlikely to have the same pessimistic outcome or associated impairmentof the limb. Thus the first combination of injury and complication couldbe more serious than the second.

There are no specific rules to match the medical outcome with regard topermanent impairment. Impairments are addressed in the filters sectionbelow.

Filters

In some embodiments, filters are used to constrain, refine or relax thecriteria that are used in finding matching closed claims. The startingsettings of the filters can be specified on a company wide basis, at auser level, or at a specific claim level (once set by the user). Examplefilter settings are:

-   -   Tight    -   Enabled    -   Loose    -   Ignore        The settings above are constraints on the range of values that        will be used in the search for precedent claims. A “tight”        setting for a parameter, such as age, will constrain the search        only finding claims whose claimant is in a narrower age band.        The “loose” setting will widen the band of claimant ages that        can be returned.        The settings of “enabled” and “ignore” refer to parameters whose        potential values are Boolean (constrained to the values of yes        or no). Gender is an example of a Boolean values attribute—it is        either enabled and only claims with the correct gender will be        returned or ignored and claims involving both sexes will be        returned.        Not all filter values have all the same potential settings.        Example filter values are:    -   State and County    -   Age    -   Gender    -   Injuries    -   Impairment    -   Litigation stage

State and County

The state/county filter can take the values “tight”, “loose” and“ignore”. The “tight” setting will constrain the search to ensure thatall claims returned match the county of the current claim. A “loose”setting will allow claims within the same state to be returned, usingall counties within the corresponding state. An “ignore” setting willseek claims anywhere throughout the United States, including thenominated state and county.

Age

For each age (or range of ages), “tight” and “loose” may be defined. Forexample, a “tight” setting for a 40 year old may be from age 30 to 45,and a “loose” setting for a 40 year old may be from 25 to 55. Examplesettings include:

Tight Loose Claimant age From age To age From age To age 0 0 5 0 5 2 0 50 5 5 3 8 3 8 8 5 12 4 14 10 7 14 6 16 13 10 18 9 19 18 14 25 14 30 2518 35 17 40 40 30 45 25 55 70 55 120 45 120 80 60 120 50 120 120 100 12090 120In the above example, the table has entries for ages 0 and 120. Thoughfew claimants will have these particular ages, they are included toprovide lower and upper bounds of theoretical potential ages. Forclaimants whose age falls in between two values in the first column,such as age 9, then the values used representing the age range will beintermediate values from the other columns. For example, if the settingfor age is “tight” then, since age 9 is half way between ages 8 and 10(which appear in the claimant age column), the derived low age valuewill be 6 (half way between 5 and 7—which are the corresponding valuefor ages 8 and 10) and the high bound will be 13 (between 12 and 14 fromthe high column).

Gender

The gender settings are “enable” and “ignore”, which correspond tomatching the claimant's gender or returning claims involving both sexesrespectively.

Injuries

The settings for injuries are “tight” and “loose” onlyFor cases whose dominant injury is demonstrable (therefore non-whiplash)the “tight” setting constrains the matching to include precedent claimswhose medical attributes match all the medical attributes of the currentclaim, excluding any trivial injuries. These medical attributes aregoverned by the medical rules as specified below. A “loose” settingwidens the matching to claims which have the same dominant medicalfeature as the current claim (the dominant medical feature is describedelsewhere in this document).For claims that are predominantly of a soft tissue spinal nature the“tight” and “loose” setting can have different effects. A “tight”setting may constrain the matching to only return claims which have atleast one of the whiplash type injuries of the current claim, and whichhave trivial demonstrable injuries if the current claim also has them orthat do not have any trivial injuries if the current claim also does nothave them. For example, for a case with a cervical sprain and a chestcontusion the cases returned will include any that have a cervicalsprain and another trivial demonstrable injury (not necessarily a chestcontusion). A “loose” setting may remove the constraint of requiring toinclude or exclude the trivial demonstrable injuries. For the aboveexample, claims would be returned which had a cervical sprain, butregardless of whether they also had any trivial demonstrable injuries.

Impairment

In a similar manner to the treatment of an age filter, impairment isconstrained to be between two values. Different values are used for“tight” and “loose”. Example settings include:

Claimant whole Tight Loose person Impairment Impairment ImpairmentImpairment impairment from to from to 0 0 0 0 0 0.1 0.1 0.5 0.1 3 3 2 42 5 5 4 6 3 8 10 8 12 7 13 20 17 23 15 25 50 40 60 35 70 60 60 100 60100

Litigation Stage

In one embodiment, potential values for litigation stage are “direct”,“unlitigated” and “suit”. The values for the filter are “enable” and“ignore”. A setting of “enable” constrains the matching to return claimswhich have the same litigation stage, as the current claim. A setting of“ignore” will return claims regardless of their litigation stage.

Attorney Representation

In an embodiment, a filter may be applied depending on whether aclaimant is represented by an attorney. In another embodiment, a filtermay be applied depending on whether a claimant is represented by aparticular attorney or a defined set of particular attorneys.

Accident Data

In an embodiment, a filter may be applied depending on whether EDR datais available for the accident that gave rise to the claim. In anembodiment, a filter may be applied depending on whether EDR data forthe accident indicates that an injury was a low-impact injury.

Fallback

In some embodiments, if insufficient claims are matched the filters maybe relaxed in order to expand the search.In order of priority the filters are relaxed in the following order,assuming filters are originally set at tightest setting

1. Injury is set to “loose”

2. Gender is set to “ignore”

3. Age is set to “loose”

4. Age is set to “ignore”

5. Jurisdiction (state and county) is set to “loose”

6. Litigation stage is set to “ignore”

7. Jurisdiction is set to “ignore”

For example if insufficient claims are found then the first fallback forthe filters is to set the injury filter to “loose”. If there are stillinsufficient claims then the gender filter is set to “ignore”. Filtersmay be relaxed in the above sequence until either enough claims arefound or the relaxation of the filters has been exhausted.If, in relaxing a filter, a large number of claims are returned, otherfilters already relaxed may be re-tightened in order to optimize thecloseness of the matched claims' attributes until it reaches close tothe minimum number of claims required. For example, if during filterrelaxation reached the 6^(th) stage (setting the litigation stage to“ignore”), and suddenly the number of claims matched rises to 100 thenall the filters whose priority is less than 6 may be re-tightened, andthen, if not enough matches are found, may be relaxed again in turnuntil the minimum threshold is reached. This task may be repeatedseveral times to optimize the closeness of the matched claims.

In certain embodiments, one or more of any of the characteristics usedfor filters described herein may be used as equalization criteria. Suchequalization criteria may be used instead of, or in addition to, theapplication of various filters. For example, the system might filterclaims based gender and adjust values using equalization values based onage.

In one embodiment the minimum number of claims used in the filteroptimization is set to 6.

Ranking the Matching Claims

In some embodiments, matching claims are ranked on a numerical scale.For example, Rank 1 matches may be the best fit, but claims of Rank 4are still similar claims. It is the number of claim attributes and towhat degree they differ between a matched claim and the current claimthat determine the rating a matched claim receives. Example attributesconsidered when determining ranking level are:

1. Dominant injury treatment or complication

2. Jurisdiction

3. Litigation stage

4. Age

5. Impairment

6. Secondary injuries

For soft tissue spine additionally:

7. Treatment time

8. Number of GP visits

9. Number of chiropractor visits

10. Number of physical therapy visits

11. Number of specialist visits

Within each rating displayed the claims are sorted by increasing GeneralDamages.

Deriving Adjusted General Damages

There will be instances where the claims that have been returned by thematching process will not be absolute matches for the current claim. Forexample, the dominant medical feature may match, but secondary medicalfeatures may be different. Or if insufficient cases were found in thenominated stage and county then claims can be returned from anotherjurisdiction. This difference in jurisdiction can be reflected indifferent settlement values for similar claims. In both cases, theGeneral Damages from the original settlement should be adjusted toreflect different jurisdiction or different secondary medical features.All returned claims may include the actual General Damages paid as wellas the adjusted General Damages.

For example, if the current claim involved a fracture of the humerusonly and the minimum required number of claims are found for the currentclaim jurisdiction, then this function would not be invoked. In someinstances, however, there may not enough claims within the onejurisdiction, for this injury. The jurisdiction filter would be relaxedat some stage and claims from other states would have been returned. Forthe sake of example, the current claim is from Massachusetts and one ofthe claims being returned is from Connecticut. A trend may be found thatConnecticut claims settle at higher monetary damages than Massachusettsclaims, for similar cases. Thus, if the Connecticut precedent is to beused for the Massachusetts claim then an adjustment would be made toreduce its settled value to Massachusetts values.

In some embodiments, the system also adjusts for differences inlitigation stage. For instance, settlements for claims already in suitare generally at higher monetary damages than for unlitigated claims,and direct claims respectively.

In order to derive the variations in settlement values from state tostate settled claims from the entire database may be analyzed. Eachclaim may be considered in turn and matching claims found from otherstates. The difference between the settlement value of this claim andthe average value from the matching claims is recorded, as a comparison.Once the entire database has been examined in this manner state by staterelativities are calculated using the stored comparisons generated foreach claim. This is performed once for claims involving demonstrableinjuries and separately for soft tissue spine claims. Thus, two sets ofrelativities may be calculated for each state.

In a similar manner the relativities associated with the differentstages of litigation may be calculated, by exhaustively examining allthe claims in the database.

More commonly, instances will exist where the claims returned will befrom the correct jurisdiction but they have different secondary medicalfeatures, because sufficient absolutely exact matches could be found.For example, if the current claim involved a fractured humerus and afractured sternum and a matching humerus fracture claim involved asprained wrist, then the current claim has a more serious secondaryinjury than the matched claim. Therefore, the projected value of thecurrent claim should be higher than the settlement value of the matchedclaim.

Learning How to Adjust for Secondary Medical Features

In an embodiment, each medical code used by the system may be assigned aPain and Suffering severity which represents the General Damagesseverity relativity. These relativities follow in general the injury,treatment and complication hierarchies described above. Each medicalcode may also been assigned a medical scale relativity parameter value(e.g., from 0 to 10). A higher the value may correspond to a moreserious medical feature belonging to the code. F or instance, thecomplication of flail chest, a life threatening respiratorycomplication, may be assigned a medical scale of 8, while a facial woundinfection is assigned 0.5. Other serious complications such as epidural,subdural or subarachnoid hematomas may be assigned a medical scale of 9.The medical scale values reflect the seriousness of a medical condition(whether this is an injury, treatment or complication) and itsrelationship to the General Damages settled. In the example above aflail chest would contribute more to the settlement than a facial woundinfection

In certain embodiments, each medical sub body part is assigned a rank.The injuries with same ranks have the same Pain and Sufferingseverities. For example the radius and ulna have the same rank and thesystem considers fracture ulna and fracture radius as the same injuriesin terms of severity.

All closed claims in the database may be examined. For the injuries, thesystem may aggregate all medical codes with the same major body part,injury code and rank, to form a set of injury categories. For treatmentsand complications the categories are constructed by aggregation of thecodes with the same medical scale. The system derives the contributionof each category of medical codes to the settlement values of theclaims. Once the values of the medical codes categories have beenderived then the Pain and Suffering severities assigned to every medicalcode are adjusted accordingly.

Prioritizing Medical Features for Each Body Part

Within each body part the medical features, being injuries, treatmentsand complications, may be listed in decreasing priority order. The firstentry may be the highest priority—it is the most severe case and will besearched for instead of any others, if it exists.

All the rules are executed for each major body part required. Thisresults in all matching injuries generating matching criteria.

Head

Skull fractures include open or closed fracture to the base of vault orthe skull. Facial fractures also include open and closed fractures.

1. Removal of an eye

2. Intracranial hematoma, head vascular injury or cerebral edema

3. Fractured skull or concussive injury with epilepsy

4. Fractured skull or concussive injury with trigeminal neuralgia orcranial nerve injury

5. Fractured skull or concussive injury with hearing loss

6. Fractured skull or concussive injury with loss of smell and taste

7. Fractured skull or concussive injury with craniotomy, craniectomy orother skull surgery

8. Fractured skull or concussive injury with vertigo or tinnitus

9. Open skull or facial fracture or laceration of face or scalp withosteomyelitis

10. Skull, orbit or nose fracture with rhinorrhea or otorrhea

11. Fractured skull without skull surgical procedures

12. Fractured jaw (mandible or maxilla)

13. Fractured facial bone (zygoma or orbit)

14. Fractured nose

15. Laceration to the eye

16. Concussive injury

17. Laceration to the scalp, ear, eyelid, mouth or face

Explanation

Loss of sight may be the highest level of severity, followed by headinjuries with accompanying intracranial hemorrhage such as epidural,subdural and subarachnoid hemorrhage. While recovery from intracranialhemorrhage may take place, some residual cerebral dysfunction may alsoexist. Posttraumatic epilepsy is a serious consequence of head injurywhich depending on its severity may have a profound affect on anindividuals ability to lead a normal life style. Head injuries withassociated cranial nerve trauma may result in sensory loss (hearing,smell and taste). Injuries to the acoustic nerve may produce vertigo ortinnitus or both, again these complications depending on the severity ofthe symptoms can seriously affect a person's ability to lead a normallife. Skull surgery is an indication that some serious brain or vascularinjury or complication was involved. Facial fractures may have both afunctional and disfiguring aftermath. Jaw fractures (mandible ormaxilla) can heal with dysfunction to mastication and may even bedisfiguring. Zygoma and orbit fractures may heal with disfigurement,similarly nasal fractures. The main implication for lacerations to thehead region is disfigurement. Eye lacerations can be simple or extremelyserious.

The severity order described above is not absolute, for example, an eyelaceration with visual impairment clearly would be a more serious injurythan where it currently lies within this hierarchy. Debilitatingepilepsy or vertigo or tinnitus would also be higher in the hierarchythan suggested above.

Chest

-   -   1. Thoracic injuries involving open thoracic or abdominal        surgery    -   2. Life threatening respiratory or cardiac complications        (including flail chest, hemothorax, pneumothorax,        pneumohemothorax, myocardial contusion, mediastinal emphysema or        pneumonia)    -   3. Intercostal neuralgia    -   4. Fractured ribs or sternum        -   a. Fractures of five or more ribs Fractures to 5, 6, 7 or 8            or more rib fractures        -   b. Fractures of 4 ribs Fractures to 3 to 6 ribs        -   c. Fractures of 3 ribs Fractures of 2 to 5 ribs        -   d. Fracture of 2 ribs Fractures of up to 3 ribs or the            sternum        -   e. Fracture of 1 rib Fracture of 1 or 2 rubs or the sternum        -   f. Fracture of the sternum Fractures of the sternum or 1 or            2 ribs    -   5. Lacerations or fractures to the internal throat structures    -   6. Internal thoracic contusions    -   7. Contusions to the internal throat structures    -   8. Laceration to the external throat    -   9. Laceration to the breast    -   10. Laceration to the chest wall

Explanation

Chest injuries requiring open chest surgery (thoracotomy) or anabdominal approach (laparotomy) may be the most potentially seriousthoracic injury. Thoracotomy for example is one of the most invasivesurgical procedures that can be undertaken. Then follows thoracic traumawith life threatening respiratory complications. Intercostal neuralgiais a painful and often intractable condition so it has been placed highin the severity hierarchy. Sternum and rib fractures follow. They aresometimes associated with lung complications such as pneumothorax orhemothorax, in which case they would be considered more serious aninjury than a corresponding fracture without lung complication. Internalthroat lacerations may be ranked higher than contusions in the overallchest severity hierarchy, lacerations to internal structures or organsare generally more serious than contusions.

Abdomen

-   -   1. Internal abdominal surgical removal or reconstruction        (nephrectomy, splenectomy, colostomy, ileostomy or jejunostomy)    -   2. Peritonitis    -   3. Fistula    -   4. Pancreatitis    -   5. Abscess or cyst    -   6. Adhesions or incisional hernia    -   7. Paralytic ileus    -   8. Internal abdominal open surgery via laparotomy    -   9. Internal abdominal surgery via laparoscopy    -   10. Abdominal injuries without surgical intervention

Explanation

Abdominal hierarchy is generally reflected by removal or repair orreconstruction to major abdominal organs and trauma or surgicalcomplications. Removal of a kidney (nephrectomy) would be seen as themost serious abdominal injury because of its potential to be lifethreatening should the remaining kidney be injured or become diseased inthe future. Removal of the spleen (splenectomy) puts the individual(particularly if he or she is young) at risk of very serious infection(post-splenectomy sepsis) and requires ongoing medication to preventagainst infection. Injuries to the small or large bowel requiringsurgery indicate serious abdominal injuries. Peritonitis heads theseverity for abdominal complications. Fistula, abscess, cyst, adhesionsand incisional hernia are all suggestive of possible further surgery.Abdominal injury with repair by laparotomy is considered more invasivethan repair by laparoscope.

Pelvis and Uritogenital

Pelvic fracture includes both open and closed fractures.

1. Internal pelvic surgery or laparotomy

2. Intra-pelvic laceration of internal organs (bladder, ureter, urethra)

3. Pelvic fistula

4. Urethral or ureteral stricture or associated urethral, ureter orbladder injury

5. Osteomyelitis of the pelvis

6. Fracture of the pelvis or dislocation of the pelvic ring

7. Laparoscopic surgical repair of internal organs

8. Intra-pelvic contusion of internal organs

9. Lacerations to the testes

10. Lacerations of the penis

11. Lacerations to the scrotum

12. Lacerations to the vulva

13. Contusions of the testes

Explanation

Lacerations to the bladder, ureter or urethra requiring surgical repairor reconstruction are considered to be the most severe pelvic injuries,followed by complications such as fistula or stricture of the ureter orurethra. Pelvic fractures are serious injuries but not considered asserious as injuries to the urinary system aforementioned. Genitallacerations can be minor or serious injuries, this would be determinedby any residual impairment that resulted. As with other body parts it isagain pointed out this severity hierarchy is not inflexible and theorder shown can change depending on factual circumstances of a claim.

Spine

Spinal fractures include open and closed fractures of the spine.Fractures, dislocations and fracture dislocations to any spinal regioninclude such injuries to any specific level within the spinal region.

-   -   1. Fracture dislocations or dislocations of the cervical spine    -   2. Fracture dislocations or dislocations of the thoracic spine    -   3. Fracture dislocations or dislocations of the lumbar spine    -   4. Spinal adhesions Any spinal region    -   5. Osteomyelitis of the spine Any spinal region    -   6. Associated spinal nerve injury Any spinal region    -   7. Traumatic spondylolisthesis Any spinal region    -   8. Fractures of the cervical spine    -   9. Fractures of the thoracic spine    -   10. Fractures of the lumbar spine    -   11. Fractures of the sacrum    -   12. Fractures of the tailbone (coccyx)    -   13. Disc herniations or ruptures of the cervical spine requiring        surgery    -   14. Disc herniations or ruptures of the thoracic spine requiring        surgery    -   15. Disc herniations or ruptures of the lumbar spine requiring        surgery    -   16. Disc herniations or ruptures of the cervical spine not        requiring surgery    -   17. Disc herniations or ruptures of the thoracic spine not        requiring surgery    -   18. Disc herniations or ruptures of the lumbar spine not        requiring surgery    -   19. Spondylosis Any spinal region    -   20. Decubitus ulcer    -   21. Bed sores

Explanation

Fracture dislocations and dislocations of the spine head the severityhierarchy, vertebral fractures although serious injuries are notconsidered as severe. Dislocations of the vertebral column have graverpotential consequences than fractures because of the increasedpossibility of spinal cord damage. The cervical region is regarded aspotentially a more serious region to be involved than the thoracic orlumbar regions. Spinal complications then follow, followed by fractures.Disc herniations or ruptures requiring disc surgery are ranked higherthan those without though of course this may not necessarily follow.Because a disc injury isn't surgically treated does not necessarily meanit is less serious than one operated on.

Arm

-   -   1. Amputations at the shoulder Any above elbow amputation    -   2. Amputations of the upper arm Forearm, elbow or above        amputation    -   3. Amputation at the elbow Elbow, forearm and upper arm        amputations    -   4. Amputation at the forearm Hand, wrist, elbow, forearm or        upper arm amputations    -   5. Amputations of the hand or wrist Hand, wrist, forearm or        elbow amputations    -   6. Amputations of the thumb Whole thumb or partial amputation    -   7. Amputations of other finger Amputation of whole finger or        partial amputation    -   8. Crush injuries to the arm or hand with associated surgery        (fasciotomy nerve repair vascular repair)    -   9. Volkmann's contracture    -   10. Reflex sympathetic dystrophy    -   11. Lacerations of the shoulder or upper arm requiring nerve        repair 3^(rd) degree nerve injury to the median, axillary or        ulnar nerves    -   12. Lacerations of the elbow or forearm requiring nerve repair        3^(rd) degree nerve injury to the radial or ulnar nerves    -   13. Crossunion of radius Synostosis involving the radius and        ulna    -   14. Lacerations of the wrist or hand requiring nerve repair        3^(rd) degree nerve injury to the radial or digital nerves    -   15. Lacerations of the thumb requiring nerve repair 3^(rd)        degree digital nerve injury    -   16. Amputations of the fingers    -   17. Avascular necrosis of humerus, radius or ulna    -   18. Avascular necrosis of the shoulder bones (scapula or        clavicle)    -   19. Avascular necrosis of the carpal bones (scaphoid, lunate,        pisiform, hamate, capitate, triquetral, trapezoid, trapezium)    -   20. Avascular necrosis of metacarpal, thumb or finger    -   21. Osteomyelitis of humerus, radius or ulna    -   22. Osteomyelitis of the shoulder bones (scapula or clavicle)    -   23. Osteomyelitis of the carpal bones (scaphoid, lunate,        pisiform, hamate, capitate, triquetral, trapezoid, trapezium)    -   24. Osteomyelitis of metacarpal, thumb or finger    -   25. Deep vein thrombosis of the arm    -   26. Nonunion of humerus, radius or ulna    -   27. Nonunion of the shoulder bones (scapula or clavicle)    -   28. Nonunion of the carpal bones (scaphoid, lunate, pisiform,        hamate, capitate, triquetral, trapezoid, trapezium)    -   29. Nonunion of metacarpal, thumb or finger    -   30. Osteoarthritis of shoulder, elbow or wrist    -   31. Osteoarthritis of hand, thumb or fingers    -   32. Delayed Union of humerus, radius or ulna    -   33. Delayed Union of the shoulder bones (scapula or clavicle)    -   34. Delayed Union of the carpal bones (scaphoid, lunate,        pisiform, hamate, capitate, triquetral, trapezoid, trapezium)    -   35. Delayed Union of metacarpal, thumb or finger    -   36. Malunion of humerus, radius or ulna    -   37. Malunion of the shoulder bones (scapula or clavicle)    -   38. Malunion of the carpal bones (scaphoid, lunate, pisiform,        hamate, capitate, triquetral, trapezoid, trapezium)    -   39. Malunion of metacarpal, thumb or finger    -   40. Fracture dislocation or dislocation of the shoulder    -   41. Fracture dislocation or dislocation of the elbow    -   42. Fracture dislocation or dislocation of the wrist    -   43. Fracture dislocation or dislocation of the hand    -   44. Fracture dislocation or dislocation of the thumb    -   45. Lacerations of the hand or wrist requiring tendon repair    -   46. Lacerations of the thumb requiring tendon repair    -   47. Associated tendon injury of hand, thumb or fingers    -   48. Lacerations of the fingers requiring tendon repair    -   49. Lacerations of the shoulder or upper arm requiring tendon        repair    -   50. Lacerations of the elbow or forearm requiring tendon repair    -   51. Associated tendon injury of shoulder, upper arm, elbow,        forearm or wrist With any other injury    -   52. Fracture of the humerus    -   53. Fractures of the forearm bones (radius or ulna)    -   54. Fractures of the shoulder bones (scapula or clavicle)    -   55. Crush injury to the thumb with associated surgery        (fasciotomy nerve repair vascular repair)    -   56. Crush injuries to the fingers with associated surgery        (fasciotomy nerve repair vascular repair)    -   57. Crush injury to the thumb not requiring surgery    -   58. Crush injuries to the fingers not requiring surgery    -   59. Fractures of the carpal bones (scaphoid, lunate, pisiform,        hamate, capitate, triquetral, trapezoid, trapezium)    -   60. Fractures of the first metacarpal (of the thumb)    -   61. Fractures of the second to fifth metacarpals (of the        fingers)    -   62. Fractures of the thumb    -   63. Fracture dislocation or dislocation of the fingers    -   64. Fractures of the fingers    -   65. Ligament injuries to the wrist with associated surgery    -   66. Ligament injuries to the hand with associated surgery    -   67. Ligament injuries to the shoulder with associated surgery    -   68. Ligament injuries to the elbow with associated surgery    -   69. Ligament injuries to the thumb with associated surgery    -   70. Ligament injuries to the fingers with associated surgery    -   71. Associated vascular injury With any other injury    -   72. Lacerations of the shoulder or upper arm requiring vascular        repair    -   73. Lacerations of the elbow or forearm requiring vascular        repair    -   74. Lacerations of the fingers requiring nerve repair    -   75. Associated nerve injury of the arm    -   76. Lacerations of the wrist or hand requiring vascular repair    -   77. Lacerations of the thumb requiring vascular repair    -   78. Lacerations of the fingers requiring vascular repair    -   79. Sprains and strains of the shoulder with associated surgery    -   80. Sprains and strains of the wrist with associated surgery    -   81. Sprains and strains of the elbow with associated surgery    -   82. Sprains and strains of the thumb with associated surgery    -   83. Sprains and strains of the fingers with associated surgery    -   84. Crush injuries to the arm or hand not requiring surgery    -   85. Ligament injuries to the wrist not requiring surgery    -   86. Ligament injuries to the hand not requiring surgery    -   87. Ligament injuries to the shoulder not requiring surgery    -   88. Ligament injuries to the elbow not requiring surgery    -   89. Ligament injuries to the thumb not requiring surgery    -   90. Ligament injuries to the fingers not requiring surgery    -   91. Bursitis, synovitis, tendonitis or tenosynovitis of        shoulder, elbow or wrist    -   92. Bursitis, synovitis, tendonitis or tenosynovitis of hand,        thumb or fingers    -   93. Sprains and strains of the shoulder not requiring surgery    -   94. Sprains and strains of the wrist not requiring surgery    -   95. Sprains and strains of the elbow not requiring surgery    -   96. Sprains and strains of the thumb not requiring surgery    -   97. Sprains and strains of the fingers not requiring surgery    -   98. Lacerations of the shoulder or upper arm not requiring        surgery    -   99. Lacerations of the elbow or forearm arm not requiring        surgery    -   100. Lacerations of the wrist or hand not requiring surgery    -   101. Lacerations of the thumb not requiring surgery    -   102. Lacerations of the fingers not requiring surgery

Explanation

In the above listing, traumatic amputations head the severity order i.e.the limb or part thereof was severed in the accident. Crush injury tothe arm or hand follows, crush injuries might be expected to result insome vascular or peripheral nerve damage with resulting muscle andfascia dysfunction. Next in severity hierarchy is major peripheral nerveinjury, minor nerve injuries are not surgically treated, those that aresuggest 3^(rd) degree nerve injuries, and some residual dysfunctionmight be expected to result. Fracture complications come next in theorder. Osteomyelitis and avascular necrosis are serious bonecomplications, the former being an infection and the latter a bonevascular problem. Nonunion is considered the most significant of thebony union complications (with the exception of cross union). Fracturedislocations and dislocations of major joints are considered slightlymore severe than fractures. Obviously not all fractures or fracturedislocations or dislocations are treated alike in terms of injuryhierarchy.

There is considerable severity overlap between these injuries with theircomplications and potential treatments. What may be ranked as amoderately severe injury may in fact end up a more serious injury thansome ranked higher in severity, this however can be related by theadjuster as the “dominant injury”.

Leg

-   -   1. Amputations at the hip Amputation at the hip or through the        thigh    -   2. Amputations though the thigh Hip, thigh, knee or lower leg        amputations    -   3. Amputations at the knee Amputation though thigh, knee or        lower leg    -   4. Amputations through the lower leg Amputations through thigh,        knee, lower leg, ankle or foot    -   5. Amputation at the ankle Amputations through knee, lower leg,        ankle or foot    -   6. Amputations through the foot Amputations through lower leg,        ankle or foot    -   7. Fracture dislocations or dislocations of the knee    -   8. Fracture dislocations or dislocations of the hip    -   9. Lacerations of the hip or thigh requiring nerve repair 3^(rd)        degree nerve injury to the femoral or sciatic nerves    -   10. Lacerations of the knee or lower leg requiring nerve repair        3^(rd) degree nerve injury to the peroneal, popliteal, tibial or        other nerves    -   11. Crush injuries of the leg or foot requiring surgery        (fasciotomy nerve repair vascular repair)    -   12. Nonunion of femur, patella, tibia or fibula    -   13. Nonunion of tarsal bones (calcaneus, cuboid, navicular,        talus or cuneiforms)    -   14. Deep vein thrombosis of the leg    -   15. Avascular necrosis of femur, patella, tibia or fibula    -   16. Avascular necrosis of tarsal bones (calcaneus, cuboid,        navicular, talus or cuneiforms)    -   17. Avascular necrosis of metatarsals, sesamoids or toes    -   18. Osteomyelitis of acetabulum, femur, patella, tibia or fibula    -   19. Osteomyelitis of tarsal bones (calcaneus, cuboid, navicular,        talus or cuneiforms)    -   20. Osteomyelitis of metatarsals, sesamoids or toes    -   21. Osteoarthritis of hip, knee or ankle    -   22. Osteoarthritis of foot or toes    -   23. Delayed union of acetabulum, femur, patella, tibia or fibula    -   24. Fractures of the femur    -   25. Fractures of the hip (acetabulum)    -   26. Fractures of the tibia    -   27. Amputation of the toes Any toes, whole or part    -   28. Nonunion of metatarsals, sesamoids or toes    -   29. Delayed union of tarsal bones (calcaneus, cuboid, navicular,        talus or cuneiforms)    -   30. Delayed union of metatarsals or toes    -   31. Malunion of acetabulum, femur, patella, tibia or fibula    -   32. Malunion of tarsal bones (calcaneus, cuboid, navicular,        talus or cuneiforms)    -   33. Malunion of metatarsals or toes    -   34. Fracture dislocations or dislocations of the ankle    -   35. Fracture dislocations or dislocations of the foot    -   36. Fractures of the hind foot (talus and calcaneus)    -   37. Ligament injuries of the knee requiring surgery    -   38. Sprain strain injuries of the knee requiring surgery    -   39. Ligament injuries of the ankle requiring surgery    -   40. Sprain strain injuries of the ankle requiring surgery    -   41. Ligament injuries of the hip requiring surgery    -   42. Sprain strain injuries of the hip requiring surgery    -   43. Sprain strain injuries of the thigh requiring surgery    -   44. Ligament injuries of the foot requiring surgery    -   45. Sprain strain injuries of the foot requiring surgery    -   46. Fracture dislocations or dislocations of the patella    -   47. Fractures of the patella    -   48. Fractures of the fibula    -   49. Fractures of the tarsal bones (cuboid, navicular, first,        second and third cuneiforms, tibial and fibular sesamoids)    -   50. Crush injuries of the toes requiring surgery (fasciotomy        nerve repair vascular repair)    -   51. Ligament injuries of the toes requiring surgery    -   52. Fractures of the forefoot (metatarsals)    -   53. Fracture dislocations or dislocations of the toes    -   54. Fractures of the toes    -   55. Associated vascular injury    -   56. Sprain strain injuries of the toes requiring surgery    -   57. Lacerations of the ankle or foot requiring tendon repair    -   58. Lacerations of the toes requiring tendon repair    -   59. Lacerations of the hip or thigh requiring tendon repair    -   60. Lacerations of the knee or lower leg requiring tendon repair    -   61. Lacerations of the hip or thigh requiring vascular repair    -   62. Lacerations of the knee or lower leg requiring vascular        repair    -   63. Lacerations of the ankle or foot requiring nerve repair    -   64. Lacerations of the toes requiring nerve repair    -   65. Lacerations of the ankle or foot requiring vascular repair    -   66. Lacerations of the toes requiring vascular repair    -   67. Crush injuries of the leg or foot not requiring surgery    -   68. Crush injuries of the toes not requiring surgery    -   69. Ligament injuries of the knee not requiring surgery    -   70. Ligament injuries of the ankle not requiring surgery    -   71. Ligament injuries of the hip not requiring surgery    -   72. Ligament injuries of the foot not requiring surgery    -   73. Ligament injuries of the toes not requiring surgery    -   74. Associated tendon injury of hip, upper leg, knee, lower leg        or ankle    -   75. Associated tendon injury of foot or toes    -   76. Associated nerve injury    -   77. Bursitis, synovitis, tendonitis or tenosynovitis of hip,        knee or ankle    -   78. Bursitis, synovitis, tendonitis or tenosynovitis of foot or        toes    -   79. Sprain strain injuries of the knee not requiring surgery    -   80. Sprain strain injuries of the hip not requiring surgery    -   81. Sprain strain injuries of the thigh not requiring surgery    -   82. Sprain strain injuries of the ankle not requiring surgery    -   83. Sprain strain injuries of the foot not requiring surgery    -   84. Sprain strain injuries of the toes not requiring surgery    -   85. Lacerations of the hip or thigh not requiring surgery    -   86. Lacerations of the knee or lower leg not requiring surgery    -   87. Lacerations of the ankle or foot not requiring surgery    -   88. Lacerations of the toes not requiring surgery

Explanation

In the listing above, traumatic amputations head the list of severityhierarchy. The follows fracture dislocations of the 2 largest joints inthe body, the knee and the hip. Knee fracture dislocation has been givenpriority over the hip, knee dislocations are orthopedic emergencies andeven when treated promptly and expertly are still likely to result inneurovascular impairment. Injuries with peripheral nerve complicationsrequiring nerve repair come next, the assumption applied here is thatbecause nerve repair is required, the nerve injury is of a third degreetype. Third degree peripheral nerve injuries do not fully heal.Extensive soft tissue injury (crush injury) is next, note: it is assumedthis injury involves soft tissues—fascia, muscle etc. Bony injuries arenot implied as being part of crush injuries. Fracture complications comenext in the hierarchy and then fractures to the major weight bearingbones. It will be noted that the fibula although a long bone is notranked along with the other bone of the lower leg, the tibia. The fibulais not weight bearing and fractures of the fibula are not considered asserious as tibia fractures.

As with the order for the other major body parts, this list is only abroad guide for leg injury severity hierarchy. Complications,treatments, prognosis and medical outcome are all factors that canchange the order in which these injuries appear in this hierarchy.

Embodiments of a subset or all (and portions or all) of the above may beimplemented by program instructions stored in a memory medium or carriermedium and executed by a processor. A memory medium may include any ofvarious types of memory devices or storage devices. The term “memorymedium” is intended to include an installation medium, e.g., a CompactDisc Read Only Memory (CD-ROM), floppy disks, or tape device; a computersystem memory or random access memory such as Dynamic Random AccessMemory (DRAM), Double Data Rate Random Access Memory (DDR RAM), StaticRandom Access Memory (SRAM), Extended Data Out Random Access Memory (EDORAM), Rambus Random Access Memory (RAM), etc.; or a non-volatile memorysuch as a magnetic media, e.g., a hard drive, or optical storage. Thememory medium may comprise other types of memory as well, orcombinations thereof.

In addition, the memory medium may be located in a first computer inwhich the programs are executed, or may be located in a second differentcomputer that connects to the first computer over a network, such as theInternet. In the latter instance, the second computer may provideprogram instructions to the first computer for execution. The term“memory medium” may include two or more memory mediums that may residein different locations, e.g., in different computers that are connectedover a network.

In some embodiments, a computer system at a respective participantlocation may include a memory medium(s) on which one or more computerprograms or software components according to one embodiment of thepresent invention may be stored. For example, the memory medium maystore one or more programs that are executable to perform the methodsdescribed herein. The memory medium may also store operating systemsoftware, as well as other software for operation of the computersystem.

In some embodiments, users (e.g., claims adjusters, process evaluators,FSO personnel) may access or operate elements of a computer system via anetwork such as a WAN or LAN. In certain embodiments, users may haveweb-enabled access to a system (e.g., via internet browser).

Further modifications and alternative embodiments of various aspects ofthe invention may be apparent to those skilled in the art in view ofthis description. Accordingly, this description is to be construed asillustrative only and is for the purpose of teaching those skilled inthe art the general manner of carrying out the invention. It is to beunderstood that the forms of the invention shown and described hereinare to be taken as embodiments. Elements and materials may besubstituted for those illustrated and described herein, parts andprocesses may be reversed, and certain features of the invention may beutilized independently, all as would be apparent to one skilled in theart after having the benefit of this description of the invention.Changes may be made in the elements described herein without departingfrom the spirit and scope of the invention as described in the followingclaims.

1-72. (canceled)
 73. A computer-implemented method for determiningamounts for use in settling insurance claims, comprising: receiving aselection of one or more equalization criteria from a defined list;automatically determining on an insurance claims processing systemequalization values from a set of closed claim data based on theselected equalization criteria; for at least one open claim, providingbodily injury data for the open claim; identifying one or more precedentclaims that match the open claim based on one or more characteristics ofthe open claim; automatically adjusting on the insurance claimsprocessing system a value for one or more of the matching precedentclaims using one or more of the equalization values; and determining anamount for the open claim based at least in part on at least oneadjusted value.
 74. The method of claim 73, wherein the amount is ageneral damages value for the open claim.
 75. The method of claim 73,wherein the amount is a recommended settlement amount for the openclaim.
 76. The method of claim 73, wherein the selection by a user ofthe one or more equalization criteria is made during installation of aclaims-matching program.
 77. The method of claim 73, further comprisingdetermining a likelihood value associated with at least one of theprecedent claims, wherein the amount for the open claim is based atleast in part on the likelihood value.
 78. The method of claim 73,wherein the amount for the open claim is determined by: determining anadjusted general damages amount for the open claim based at least inpart on at least one equalized value; and increasing or decreasing theadjusted general damages amount based on at least one pending claimadjustment.
 79. The method of claim 73, wherein the equalizationcriteria comprises a locality of an accident.
 80. The method of claim73, wherein the equalization criteria comprises a sub-state locality ofan accident.
 81. The method of claim 73, wherein the equalizationcriteria comprises a claim type.
 82. The method of claim 73, wherein theequalization criteria comprises a county of an accident.
 83. The methodof claim 73, wherein the equalization criteria comprises secondaryinjury type.
 84. The method of claim 73, wherein the equalizationcriteria comprises jurisdiction.
 85. (canceled)
 86. The method of claim73, wherein identifying the one or more precedent claims that match anopen claim comprises applying at least one filter.
 87. The method ofclaim 73, wherein identifying the one or more precedent claims thatmatch an open claim comprises receiving at least one selection from userspecifying at least one filter and applying the at least one filter. 88.The method of claim 73, wherein identifying the one or more precedentclaims that match an open claim comprises determining whether a majorinjury for the open claim is predominantly a demonstrable injury or nota demonstrable injury.
 89. The method of claim 73, wherein identifyingthe one or more precedent claims that match an open claim comprisesdetermining a most injured body part for the open claim.
 90. The methodof claim 73, wherein identifying the one or more precedent claims thatmatch an open claim comprises determining one or more medical codes forat least one injury to a claimant for the open claim.
 91. The method ofclaim 73, wherein identifying the one or more precedent claims thatmatch an open claim comprises identifying a dominant medical featureassociated with at least one injury to a claimant for the open claim.92. A system, comprising: a processor; a memory coupled to the processorand configured to store program instructions executable by the processorto implement: receiving a selection by a user of one or moreequalization criteria from a defined list; determining equalizationvalues from a set of closed claim data based on the selectedequalization criteria; and for at least one open claim: providing bodilyinjury data for the open claim; identifying one or more precedent claimsthat match an open claim based on one or more characteristics of theopen claim; adjusting a value for one or more of the matching precedentclaims using one or more of the equalization values; and determining anamount for the open claim based at least in part on at least oneadjusted value.
 93. A tangible, computer readable medium comprisingprogram instructions, wherein the program instructions arecomputer-executable to implement: receiving a selection by a user of oneor more equalization criteria from a defined list; determiningequalization values from a set of closed claim data based on theselected equalization criteria; for at least one open claim: providingbodily injury data for the open claim; identifying one or more precedentclaims that match an open claim based on one or more characteristics ofthe open claim; adjusting a value for one or more of the matchingprecedent claims using one or more of the equalization values; anddetermining an amount for the open claim based at least in part on atleast one adjusted value. 94-168. (canceled)